Radiology report clarity: a cohort study of structured reporting compared with conventional dictation.
OBJECTIVE
The aim of this study was to determine if radiology residents who use a structured reporting system (SRS) produce reports of greater clarity than residents who use free-text dictation to report cranial MR imaging in patients with clinical suspicion of stroke.


METHODS
This double-cohort study included residents creating reports for 25 cranial MR imaging studies using an SRS in the intervention group and free text in the control group (report n = 1,685). Attending physicians from multiple subspecialties were surveyed seeking clarity ratings of randomly selected reports. Two neuroradiology fellows rated the clarity of 180 of the reports. Clarity ratings were analyzed by using Wilcoxon's signed-rank test for paired data and the Mann-Whitney U test for unpaired data.


RESULTS
Forty-three of 95 surveyed physicians returned completed surveys, with mean clarity ratings for SRS (4.9) and free-text (5.1) reports that did not differ significantly. Respondents' comments most often referred to confusing syntax, unfamiliar terms, or format preferences. Fellow raters rated the clarity of SRS reports lower than that of free-text reports (P < .001).


CONCLUSIONS
The use of an SRS to create MRI reports did not seem to improve or worsen attending physicians' perceptions of report clarity. Experience level may affect clarity-related report preferences. Future SRS should probably include definitions of key terms and be formatted to minimize syntactical errors.
Johnson
Annette J
AJ
Department of Radiology, Wake Forest University Baptist Medical Center, Winston-Salem, North Carolina 27157, USA. anjohnso@wfubmc.edu
Chen
Michael Y M
MY
Zapadka
Michael E
ME
Lyders
Eric M
EM
Littenberg
Benjamin
B
D015331:Cohort Studies; D006801:Humans; D008499:Medical Records / Q000592:standards*; D018024:Peer Review, Health Care; D011871:Radiology / Q000379:methods* / Q000706:statistics & numerical data; D011795:Surveys and Questionnaires