Structured reporting of x-rays for atraumatic shoulder pain: advantages over free text?

BACKGROUND: To analyse structured and free text reports of shoulder X-ray examinations evaluating the quality of reports and potential contributions to clinical decision-making.

METHODS: We acquired both standard free text and structured reports of 31 patients with a painful shoulder without history of previous trauma who received X-ray exams. A template was created for the structured report based on the template ID 0000154 (Shoulder X-ray) from radreport.org using online software with clickable decision trees with concomitant generation of structured semantic reports. All reports were evaluated regarding overall quality and key features: content, information extraction and clinical relevance.

RESULTS: Two experienced orthopaedic surgeons reviewed and rated structured and free text reports of 31 patients independently. The structured reports achieved significantly higher median ratings in all key features evaluated (P < 0.001), including facilitation of information extraction (P < 0.001) and better contribution to subsequent clinical decision-making (P < 0.001). The overall quality of structured reports was significantly higher than in free text report (P < 0.001).

CONCLUSIONS: A comprehensive structured template may be a useful tool to assist in clinical decision-making and is, thus, recommended for the reporting of degenerative changes regarding X-ray examinations of the shoulder.