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SVMIC Risk Basics: Radiology
Advantages & Disadvantages of a Structured Report
Structured reports created with standardized templates are gaining
popularity, especially among trainees. Advantages of structured reports
include: uniformity and improved communication with referring providers,
improved data mining and peer review process, lesser likelihood of
pertinent information being omitted by the radiologist, and facilitation
of the drawing of attention to critical findings. Disadvantages include:
potential decrease in productivity due to radiologists not keeping their
eyes on images while assessing templates (the so-called eye dwell
problem), possible unsuitability of a report for complicated cases or cases
in which a single disease entity affects multiple organs, and possible
lengthening of a report in a normal case.
A meticulous and well-written report is the best way for radiologists to
care for their patients. Furthermore, a well-worded report can be the
deciding factor in a successful defense against a malpractice action. Even
if a radiologist identifies all the findings and makes a brilliant diagnosis,
deficient reporting and communication of the information can result in a
medicolegal debacle.
Communication is not limited to the written report. Communication errors
often occur during handoffs. This is especially evident in the cardiac
catheterization and endoscopy labs, as well as the radiology imaging
settings where healthcare practitioners may administer medications
such as contrast media, adjust rates of fluids, and flush IV access lines.
Continuity of care is a frequent problem in a hospital setting.
What if the referring physician has signed out to someone else? Or,
what if the radiologist’s shift has ended and he or she must pass off
the responsibility? What is the timeframe for expecting a response for
an emergency department referral? When a call is made to a referring
physician, how is it documented? Let’s a take a look at a case example.
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