Acr radiology report template

The actual word description must appear. W e recommend that you take into consideration the following issues as you develop your procedures:. You may use these as is, modify them, or create your own lay reports.

We also recommend that you use a log or your RIS system to track when the written lay summary is sent. Tell every patient that they should expect to receive a lay summary report within "X" days no more than 30 days by law. Providing the patient with an approximate date of arrival may decrease anxiety and phone calls. If you choose to hand the patient a written lay summary at the time of the appointment, you should consider the psychosocial impact of how this is done.

Having a professional such as a radiologist or a nurse verbally review the summary with the patient may reduce patient anxiety. The importance of the correlative breast physical exam should be discussed in the written lay summary, especially for self-referred patients. In , with strong support from radiology department chair E. Before Montefiore instituted structured reporting, its radiologists typically used traditional narrative reports.

Goldberg-Stein says the problem is that narrative reports are highly variable, and the actionable information within them may be hidden. Danielle B. Weinman, MD, emergency medicine attending physician at Montefiore, says she spent a lot of time scouring the unstructured reports to find the information she needed to care for patients. With this in mind, they began working together to develop a plan for instituting structured reporting within the department and pitched the idea to Amis, who was immediately receptive to the proposal.

After giving his approval for the project, Amis worked with Goldberg-Stein and Scheinfeld to outline three project criteria: First, the project would focus on CT, MRI, and ultrasound reports. Second, they would develop the templates using a consensus approach, with input from radiologists throughout the department. And finally, while findings would be presented in a structured order within the report, the radiologists would still be able to describe the findings in the manner they wanted no standardized lexicon was mandated.

It was extremely important to me that we got input from the members of each division and that we gave them some latitude in how they phrased their interpretations.

Once the ground rules were established, Goldberg-Stein and Scheinfeld drove the project. Their first step was to educate their colleagues about structured reporting. They delivered presentations during staff and resident meetings, publicized the goals of the structured reporting initiative through internal communication channels, disseminated examples of structured reports, and shared several peer-reviewed papers and other literature about the benefits and challenges of structured reporting.

From there, Goldberg-Stein and Scheinfeld asked the radiologists to provide their impressions of structured reporting through an online survey. Eighty-two radiologists participated in the survey, the results of which indicated that while 79 percent of residents favored instituting structured reporting, only 39 percent of attendings approved.

Twenty three percent of attendings and 7 percent of residents opposed the move, and the remaining respondents were unsure how they felt about structured reporting. Mordecai Koenigsberg, MD, FACR, director of ultrasonography and director of the residency program at Montefiore, was one of the radiologists who were initially skeptical of the initiative. Koenigsberg quickly realized his assumptions about the process were inaccurate.

The committee was then divided into six subcommittees that corresponded with the six primary subspecialties that perform cross-sectional imaging: abdominal, cardiothoracic, musculoskeletal, pediatric, ultrasound, and neuroradiology. These subcommittees were responsible for crafting the initial drafts of the reporting templates. As the subcommittees created the draft templates, they rolled each template out for a limited trial with the radiologists who read those exams most often.

During this second two-week trial, the co-chairs again collected feedback from the radiologists and shared it with the subcommittee members, who voted on whether to implement each suggested change. They then shared the voting results with the entire department. This transparent approach was critical to getting everyone to go along with the project. Following review, there may be a request for additional details such as program need, quality gap, covered clinical conditions, prevalence of condition, and potential committee members.

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