[Standardizing the radiologic report -- norm DIN 6827-5].
OBJECTIVE
According to the current German "Rules and Regulation for the Application of X-rays" (RöV), a radiological report has to be issued whenever a person undergoes an examination involving x-rays. Since the RöV is not specific as to its contents, the German Radiology Standards Committee (NAR) has developed a standard for the reports. The scope of this reporting standard was expanded beyond x-ray procedures to all imaging modalities.


METHODS
The radiologic report describes the type of examination performed on the patient. Following the "DICOM Structured Report" information model, the report is structured in form of a document tree. The report must be archived in printed form or digitally.


RESULTS
The report is thematically divided into six sections. Within each section, the data are condensed to the smallest still meaningful information unit. For each entry, it is stated whether it is obligatory or optional.


CONCLUSIONS
The reports according to the standards of the NAR comply with the RöV. Standards prescribing a structure can be used as guide for uniform reporting, as appropriate for printed reports. By consistently following the DICOM standards, future international standards for medical contents can be integrated into radiologic reports.
Hackländer
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Klinik für Radiologie, HELIOS-Klinikum Wuppertal. thacklaender@wuppertal.helios-kliniken.de
D005858:Germany; D006801:Humans; D008499:Medical Records / Q000592:standards*; D016347:Medical Records Systems, Computerized / Q000592:standards*; D011871:Radiology / Q000592:standards*; D011873:Radiology Information Systems / Q000592:standards*
Standardisierung des radiologischen Befundberichtes -- Norm DIN 6827-5.