Structured reporting of CT examinations in acute pulmonary embolism.

OBJECTIVES: 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.

CONCLUSION: 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.