RSNA 2017: Contextual radiology reporting templates: Structured Reporting 2.0?

Radiology reports prepared using structured report templates offer the advantages of consistency of language, clarity, and content completeness compared to conventional individually dictated reports. Their standardized language and specific data format also facilitates research investigations. But they have limitations.

Mark Mamlouk, MD, an assistant clinical professor of radiology at the University of California San Francisco School of Medicine, suggests that contextual report templates represent the second generation of structured reporting. He makes a case for their use in a RSNA poster presentation (IN102-ED-X).

Contextual reporting is defined as structured reports that are contextual to the diagnosis or exam indication, as compared to current structured reporting templates that are exam or modality based. Contextual reports provide specific content for commonly requested diseases and incorporate pertinent positives and negatives. Contextual templates are individually tailored to the diagnosis and ensure that all pertinent issues are addressed. Unlike structured report templates, they help guide a radiologist to the specific imaging findings germane to the diagnosis.

Like well-designed structured reports, contextual templates permit rapid dictation due to its tailored focus, and many fields can be rapidly completed or scrolled through. The systematic nature of the contextual template helps a radiologist put all the pieces of a specific radiology report together.

A contextual template can provide related information that a radiologist may not remember by memory and need to reference. As an example, a contextual  template for a sinus CT can provide a list of all of the sinus variants. A contextual template for dementia can inform a radiologist of the most common neurodegenerative etiologies.

Dr. Mamlouk contents that contextual templates improve report quality by addressing every item that should be reported. Just as report recipients have responded very positively to reports prepared with the use of structured report templates, Dr. Mamlouk states that ordering physician recipients should be similarly or more satisfied when contextual templates are used. Radiology residents and fellows can be more confident that all clinical information needed in the report will be addressed, and that when these templates are used, they also may serve as an educational tool.

The RSNA poster displays contextual templates for a variety of clinical scenarios. A  neck CT to confirm or rule out cancer addresses the major items desired by an ordering physician for a suspicious potential cancer cases. Fields for findings of a suspicious tumor include location, size, a description, and presence/absence of bony invasion, vascular encasement and perineural spread. A category for the presence/absence of suspicious lymph nodes includes side/level(s), a description of the largest node, the presence/absence of extracapsular extension, and a field to describe other findings.