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Quantifying Language Before and After Instituting Structured CT Reports.

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Citation: Journal of the American College of Radiology. 14(11):1444-1450, 2017 NovPMID: 28633922Institution: MedStar Good Samaritan Hospital | MedStar Montgomery Medical Center | MedStar Union Memorial Hospital Form of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: *Documentation/st [Standards] | *Radiography, Abdominal | *Radiology Information Systems/st [Standards] | *Terminology as Topic | *Tomography, X-Ray Computed | Guideline Adherence | Guidelines as Topic | Humans | Quality ImprovementYear: 2017 ISSN:

1546-1440

Name of journal: Journal of the American College of RadiologyAbstract: AIM: Our aim was to quantify the language in abdominopelvic CT reports before and after implementing structured reporting templates, specifically evaluating the terms normal and unremarkable.CONCLUSIONS: When comparing language before and after implementing structured reports, we found an increase in the frequency of normal, without any significant change in number of words per report. The increase in normal in posttemplate reports reflects a trend toward more definitive reporting, which may increase clarity and satisfaction among referring physicians. The increased use of the less definitive term unremarkable identifies an area in need of further training and improvement in our department.Copyright 2017 American College of Radiology. Published by Elsevier Inc. All rights reserved.METHODS: We performed a search of our database for all CT abdomen and pelvis examinations before and after full template implementation. There were 1,753 studies included-878 "pretemplate" reports, 875 "posttemplate" reports. Pre- and posttemplate reports were analyzed for word count in preliminary report, word count in final report, number of changed words between preliminary and final report, and frequency of normal and unremarkable. The averages of each data point for both pre- and posttemplate reports were calculated and compared.RESULTS: Between all pre- and posttemplate reports, the total number of words and number of changes between preliminary and final reports was not significantly changed. The frequency of the word normal increased from an average of 5.29 (pretemplate) to 8.92 (posttemplate) per report (P < .0001). The frequency of the word unremarkable increased from an average of 0.11 (pretemplate) to 0.22 (posttemplate) per report (P < .0001).All authors: Ascher SM, Filice R, Ross SL, Somwaru ASFiscal year: FY2017Digital Object Identifier:

https://dx.doi.org/10.1016/j.jacr.2017.04.032

Date added to catalog: 2017-06-22

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Title notes ( 6 )

Holdings
Item type	Current library	Collection	Call number	Status	Date due	Barcode
Journal Article	MedStar Authors Catalog	Article	28633922	Available		28633922

AIM: Our aim was to quantify the language in abdominopelvic CT reports before and after implementing structured reporting templates, specifically evaluating the terms normal and unremarkable.

CONCLUSIONS: When comparing language before and after implementing structured reports, we found an increase in the frequency of normal, without any significant change in number of words per report. The increase in normal in posttemplate reports reflects a trend toward more definitive reporting, which may increase clarity and satisfaction among referring physicians. The increased use of the less definitive term unremarkable identifies an area in need of further training and improvement in our department.

METHODS: We performed a search of our database for all CT abdomen and pelvis examinations before and after full template implementation. There were 1,753 studies included-878 "pretemplate" reports, 875 "posttemplate" reports. Pre- and posttemplate reports were analyzed for word count in preliminary report, word count in final report, number of changed words between preliminary and final report, and frequency of normal and unremarkable. The averages of each data point for both pre- and posttemplate reports were calculated and compared.

RESULTS: Between all pre- and posttemplate reports, the total number of words and number of changes between preliminary and final reports was not significantly changed. The frequency of the word normal increased from an average of 5.29 (pretemplate) to 8.92 (posttemplate) per report (P < .0001). The frequency of the word unremarkable increased from an average of 0.11 (pretemplate) to 0.22 (posttemplate) per report (P < .0001).

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