title: Structured reporting of MRI of the shoulder - improvement of report quality?
abstract: OBJECTIVE
  To evaluate the effect of structured reports (SRs) in comparison to non-structured narrative free text (NRs) shoulder MRI reports and potential effects of both types of reporting on completeness, readability, linguistic quality and referring surgeons' satisfaction.
  
  
  METHODS
  Thirty patients after trauma or with suspected degenerative changes of the shoulder were included in this study (2012-2015). All patients underwent shoulder MRI for further assessment and possible surgical planning. NRs were generated during clinical routine. Corresponding SRs were created using a dedicated template. All 60 reports were evaluated by two experienced orthopaedic shoulder surgeons using a questionnaire that included eight questions.
  
  
  RESULTS
  Eighty per cent of the SRs were fully complete without any missing key features whereas only 45% of the NRs were fully complete (p < 0.001). The extraction of information was regarded to be easy in 92% of the SRs and 63% of the NRs. The overall quality of the SRs was rated better than that of the NRs (p < 0.001).
  
  
  CONCLUSIONS
  Structured reporting of shoulder MRI improves the readability as well as the linguistic quality of radiological reports, and potentially leads to a higher satisfaction of referring physicians.
  
  
  CONCLUSIONS
  • Structured MRI reports of the shoulder improve readability. • Structured reporting facilitates information extraction. • Referring physicians prefer structured reports to narrative free text reports. • Structured MRI reports of the shoulder can reduce radiologist re-consultations.
authors.affiliation: Department of Clinical Radiology, Ludwig-Maximilians-University (LMU), Campus Großhadern, Marchioninistraße 15, 81377, Munich, Germany. Sebastian.Gassenmaier@med.uni-muenchen.de.
authors.forename: Sebastian
authors.initials: S
authors.lastname: Gassenmaier
authors.affiliation: Department of Clinical Radiology, Ludwig-Maximilians-University (LMU), Campus Großhadern, Marchioninistraße 15, 81377, Munich, Germany.
authors.forename: Marco
authors.initials: M
authors.lastname: Armbruster
authors.affiliation: Department of Knee, Hip and Shoulder Surgery, Schön Klinik München Harlaching, Munich, Germany.|Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-University (LMU), Campus Innenstadt, Munich, Germany.
authors.forename: Florian
authors.initials: F
authors.lastname: Haasters
authors.affiliation: Department of General, Trauma and Reconstructive Surgery, Ludwig-Maximilians-University (LMU), Campus Innenstadt, Munich, Germany.
authors.forename: Tobias
authors.initials: T
authors.lastname: Helfen
authors.affiliation: Institute of Clinical Radiology and Nuclear Medicine, University Medical Center Mannheim, Medical Faculty Mannheim - Heidelberg University, Heidelberg, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Henzler
authors.affiliation: Ambulatory Health Care Center Radiology & Nuclear Medicine, Fürth, Germany.|Department of Diagnostic Radiology, Friedrich-Alexander University, Erlangen-Nuremberg, Germany.
authors.forename: Sedat
authors.initials: S
authors.lastname: Alibek
authors.affiliation: Department of Trauma Surgery, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
authors.forename: Dominik
authors.initials: D
authors.lastname: Pförringer
authors.affiliation: Department of Clinical Radiology, Ludwig-Maximilians-University (LMU), Campus Großhadern, Marchioninistraße 15, 81377, Munich, Germany.
authors.forename: Wieland H
authors.initials: WH
authors.lastname: Sommer
authors.affiliation: Department of Clinical Radiology, Ludwig-Maximilians-University (LMU), Campus Großhadern, Marchioninistraße 15, 81377, Munich, Germany.
authors.forename: Nora N
authors.initials: NN
authors.lastname: Sommer
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D005260:Female; D006801:Humans; D008279:Magnetic Resonance Imaging; D008297:Male; D008875:Middle Aged; D058996:Quality Improvement; D011871:Radiology / Q000592:standards; D012017:Referral and Consultation; D058028:Research Report / Q000592:standards*; D012189:Retrospective Studies; D012782:Shoulder / Q000000981:diagnostic imaging*; D055815:Young Adult
keywords: MRI; Medical informatics; Quality improvement; Radiology; Shoulder