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Guidelines

• Make all measurements in 0.0 mm.  With new technology, higher MP monitors, and magnification, we might as well report what we get.  Docs feel like they're getting more value.
• Measurements i make are usually 2 dimensions on axial and the 3rd is CC.
• Make your macros kinda long.  At a county hospital you want to keep them short, but in outpatient beverly hills you want to keep them long.  Make them feel like they're getting more value.
• Add Images.  It takes 3 seconds, but the referring docs love it.
• Document who you spoke to.  I prefer to say "the findings and history were reviewed with the referring physician at the time of dictation" because it is less threatening to referring doc and all the date and time is recorded in the pacs anyways.

Links:

• ChestX-Ray.com:  guidelines and references
• Franklin-Seidelman: samples of radiology reports
• RadLex - Feasibility study to develop a unified lexicon for indexing medical imaging resources.
• The Future of Radiology Reporting (pdf, 2MB) - by B.Reiner, E. Siegel, K. Shashtri, from Electronic Reporting in the Digital Medical Enterprise, SCAR U.
• DICOM SR book - comprehensive (394 pages) book about the structured reporting extension to the DICOM standard.
• Langlotz Bibliography - organized by topic.
• SPIDER Bibliography - 1998 list of annotated references covering the evolution of 30 years of structured reporting research.
• Introduction to SR.ppt - slides by Dr. Dean Bidgood (247 KB).
• The Next Digital Frontier. Decisions in Imaging Economics, 6/2003.
• eDictation aims to make dictation faster, cheaper. Auntminnie.com, 1/2002.
• New radiology technology streamlines patient care. Triad Business News, 6/2002.
• New reporting methods may provide competitive edge. RSNA News, 3/2002.
• 4-year case study of 160,000 structured reports (pdf). StructuRad LLC, RSNA presentation, 11/2001.
• Structured reporting in radiology, SHSRR, 12/2000.

Vendors:

• eDictation - eDictation uses a combination of structured reporting, electronic signature and speech recognition to create and distribute radiology reports. The application automatically remembers unique terms and phrases to produce one-click reports for many common combinations of findings.  See the site for an animated demo.
• REX by PointDx - PointDx's flagship product, REX, integrates image analysis and structured reporting in a unique workflow process, creating a new paradigm for radiology reporting. The inefficient and costly steps associated with analysis, dictation, transcription, approval and distribution are reduced to a single step, permitting instantaneous distribution of web-based reports.
• StructuRad - The StructuRad application features an extensive set of knowledge base modules for generating report phrases, based on decision trees developed over 5 years by practicing radiologists.  presentation.pdf (794KB)
• PenRad - Structured reporting for mammographers.
• Cyberpulse - Clinical reporting for cardiologists.