The clinical report is an essential part of the service you provide to your patients. As a tool that communicates information to referring physicians, records that information for future use and serves as the legal record that documents the episode of care, it is of the utmost importance that the report be uniform, comprehensive, easily managed and "readable" to humans and machines alike.
The RSNA radiology reporting initiative is improving reporting practices by creating a library of clear and consistent report templates. These templates make it possible to integrate all of the evidence collected during the imaging procedure, including clinical data, coded terminology, technical parameters, measurements, annotations and key images. Twelve subcommittees of subspecialty experts have created a library of best-practices radiology report templates. They are free and not subject to license restrictions on their reuse. These report templates:
Through this initiative, RSNA is encouraging reporting vendors to develop software products that enable radiologists to create high-quality radiology reports more efficiently.
The report template library serves as a starting point for radiology practices wishing to improve the quality of their reports by standardizing format, content and structure. These new report templates represent best-practices that can be adapted and adopted based on your local practice patterns. The templates are published in a form that is accessible to you—whether you use automated speech recognition or other reporting tools.
In addition to the clinical benefits, these templates have advantages for research and education. For researchers, these report templates capture information in a uniform, easily extracted format that facilitates clinical, translational and health services research. Educators find these templates can help trainees learn the important elements of reports in each subspecialty area and encourage the proper use of radiology terms, such as those found in RadLex™.
Beginning in 2009, twelve RSNA template development subcommittees—comprising over 100 experts—created 68 radiology report templates in collaboration with fourteen subspecialty organizations. A radiology vendor forum attracted a dozen companies who demonstrated their radiology reporting software and learned how they can incorporate the new templates into their systems. These vendors will continue to be engaged through the RSNA IHE platform. There are now more than 100 templates available in the RSNA template library.
The following publications have been authored by the committee and its members:
Find updates on the committee activity, reporting templates, technical resources and link to the discussion forum.
Access free reporting templates to create uniformity and efficiency within the clinical reporting process.