title: Critical finding capture in the impression section of radiology reports.
abstract: BACKGROUND
  Radiology reports communicate imaging findings to ordering physicians. The substantial information in these reports often causes physicians to focus on the summarized "impression" section. This study evaluated how often a critical finding is documented in the report's "impression" section and describes how an automated application can improve documentation.
  
  
  METHODS
  A retrospective review of all chest CT scan reports finalized between October, 2009 and September, 2010 at an academic institution was performed. A natural language processing application was utilized to evaluate the frequency of reporting a pulmonary nodule in the "impression" section, versus the "findings" section of a report.
  
  
  RESULTS
  Results showed 3,401 reports with documented pulmonary nodules in the "findings" section, compared to 2,162 in the "impression" section - a 36.4% difference.
  
  
  CONCLUSIONS
  The study revealed significant discrepant documentation in the "findings" versus "impression" sections. Automated systems could improve such critical findings documentation and communication between ordering physicians and radiologists.
authors.affiliation: Brigham and Women's Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Esteban F
authors.initials: EF
authors.lastname: Gershanik
authors.forename: Ronilda
authors.initials: R
authors.lastname: Lacson
authors.forename: Ramin
authors.initials: R
authors.lastname: Khorasani
mesh_terms: D006801:Humans; D008168:Lung / Q000000981:diagnostic imaging*; D055613:Multiple Pulmonary Nodules / Q000000981:diagnostic imaging; D009323:Natural Language Processing; D011873:Radiology Information Systems; D012189:Retrospective Studies; D003074:Solitary Pulmonary Nodule / Q000000981:diagnostic imaging*; D009626:Terminology as Topic; D014057:Tomography, X-Ray Computed