title: The quality of gastroenterological reports based on free text dictation: an evaluation in endoscopy and ultrasonography.
abstract: The majority of physicians consider the use of free dictation for medical reports to be essential in many domains. One of the main criticisms of structured data entry is the possible lack of flexibility and completeness. Electronic documentation systems exist for endoscopy and ultrasonography examinations which are based on structured input as well as on free dictation. Endoscopy and ultrasonography reports based on free dictation were evaluated for omissive errors. The data evaluated was drawn from a database of 18,239 gastroscopy and 3,340 colonoscopy reports dictated by 28 physicians over 74 months, and 18,834 ultrasonography reports dictated by 37 physicians over 42 months. The error rates varied from 0% to 41.8% depending upon the particular feature and the particular examination, but were usually below 15%. The results were independent of the experience of the examiner. This study provides baseline measurements of omissive error rates for selected findings in gastrointestinal endoscopy and abdominal ultrasonography which can be used as standards for the development and evaluation of systems for collection of clinical data.
authors.affiliation: Abteilung Innere Medizin II, Medizinische Universitätsklinik, Ulm, Germany.
authors.forename: K
authors.initials: K
authors.lastname: Kuhn
authors.forename: W
authors.initials: W
authors.lastname: Swobodnik
authors.forename: R S
authors.initials: RS
authors.lastname: Johannes
authors.forename: T
authors.initials: T
authors.lastname: Zemmler
authors.forename: E F
authors.initials: EF
authors.lastname: Stange
authors.forename: H
authors.initials: H
authors.lastname: Ditschuneit
authors.forename: M
authors.initials: M
authors.lastname: Classen
mesh_terms: D003628:Database Management Systems; D004066:Digestive System Diseases / Q000175:diagnosis; D016099:Endoscopy, Gastrointestinal; D005069:Evaluation Studies as Topic; D006801:Humans; D008499:Medical Records / Q000592:standards*; D016347:Medical Records Systems, Computerized; D014463:Ultrasonography