structured reporting

What is structured reporting?

Structured reporting enables the capture of radiology report information so that it can be retrieved later and reused. A key feature of a structured report is consistent organization. A report of an abdominal CT study might follow subheadings that describe each of the anatomic areas listed in the report, such as the liver, spleen, pancreas, and kidneys. This feature of structured reporting is sometimes called “itemized reporting” or “standardized reporting” and is preferred by referring physicians, presumably because specific information can be found more easily than in a narrative report. There are no reliable data on the frequency with which reports of this type are currently used. Structured reports also use standard language.

When defined terms from a standard lexicon are associated with imaging reports, the information in the report becomes more accessible and reusable. For many years, mammography has fostered the use of structured reporting as strictly defined—choosing from a limited set of options, such as the six Breast Imaging Reporting and Data System (BI-RADS) categories, to express the likelihood of cancer on a mammogram. BI-RADS reduces the variability and improves the clarity of communication among physicians. Correlation of the recorded structured data items to histopathologic findings (often performed automatically) provides regular feedback to radiologists on their strengths and weaknesses, improving the overall quality of mammographic interpretation.

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