title: Structured reporting of CT examinations in acute pulmonary embolism.
abstract: OBJECTIVE
  To evaluate the effect of structured reporting of CT pulmonary angiography (CTPA) studies on the content, clarity and clinical usefulness of radiology reports in acute pulmonary embolism (PE).
  
  
  METHODS
  Conventional and structured reports were generated for 41 patients with a CTPA positive for acute PE. Conventional reports were dictated in a free-text form using speech recognition; structured reports contained a consistent ordering of observations with standardized subheadings. Conventional reports were compared to standardized structured reports. Two general internists and two pulmonologists rated their satisfaction with the clarity and content of the report and its clinical usefulness and hypothetically assigned the patients to a suitable disposition and therapy.
  
  
  RESULTS
  Overall, structured reports received higher ratings for content (median rating 10.0 vs. 8.5, p < 0.0001) and clarity (median rating 10.0 vs. 8.0). The increase in satisfaction with clarity was significant for both subgroups (p < 0.0001), while the increase in satisfaction with content was significant for pulmonologists only (p < 0.0001). The clinical utility of radiology reports improved with structured reporting overall (p = 0.004) and for pulmonologists (p = 0.0005). There were no significant differences in the patient disposition or therapy.
  
  
  CONCLUSIONS
  Referring clinicians perceive structured CTPA reports as superior in clarity. Pulmonologists also appreciate structured reports as providing better content and clinical utility. Structured reporting does not appear to alter patients' management in acute PE.
authors.affiliation: Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany. Electronic address: bastian.sabel@med.uni-muenchen.de.
authors.forename: Bastian O
authors.initials: BO
authors.lastname: Sabel
authors.affiliation: Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
authors.forename: Jessica L
authors.initials: JL
authors.lastname: Plum
authors.affiliation: Department of Internal Medicine V, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
authors.forename: Nikolaus
authors.initials: N
authors.lastname: Kneidinger
authors.affiliation: Department of Internal Medicine V, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
authors.forename: Gabriela
authors.initials: G
authors.lastname: Leuschner
authors.affiliation: Department of Internal Medicine II, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
authors.forename: Leandra
authors.initials: L
authors.lastname: Koletzko
authors.affiliation: Department of Internal Medicine II, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
authors.forename: Bijan
authors.initials: B
authors.lastname: Raziorrouh
authors.affiliation: Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
authors.forename: Regina
authors.initials: R
authors.lastname: Schinner
authors.affiliation: Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
authors.forename: Wolfgang G
authors.initials: WG
authors.lastname: Kunz
authors.affiliation: Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
authors.forename: Franziska
authors.initials: F
authors.lastname: Schoeppe
authors.affiliation: Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
authors.forename: Kolja M
authors.initials: KM
authors.lastname: Thierfelder
authors.affiliation: Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
authors.forename: Wieland H
authors.initials: WH
authors.lastname: Sommer
authors.affiliation: Institute for Clinical Radiology, Ludwig-Maximilians-University Hospital, Marchioninistr. 15, 81377 Munich, Germany.
authors.forename: Felix G
authors.initials: FG
authors.lastname: Meinel
mesh_terms: D000208:Acute Disease; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001291:Attitude of Health Personnel; D004282:Documentation / Q000592:standards*; D005260:Female; D006801:Humans; D033181:Information Dissemination; D008297:Male; D008499:Medical Records / Q000592:standards*; D008875:Middle Aged; D010465:Perception; D011237:Predictive Value of Tests; D011379:Prognosis; D011655:Pulmonary Embolism / Q000000981:diagnostic imaging* / Q000628:therapy; D000072106:Pulmonologists / Q000523:psychology; D012189:Retrospective Studies; D049250:Speech Recognition Software; D014057:Tomography, X-Ray Computed; D055815:Young Adult
keywords: Chest CT; Computed tomography pulmonary angiography; Pulmonary embolism; Report quality; Structured reporting