John Stewart MD, Presenter: Nothing to Disclose

To automatically convert a brief, disorganized radiology report into a high quality structured and itemized radiology report.  This reduces dictation time while allowing the radiologist to focus their attention on the images under review rather than on the text of the dictation.

A very brief header is inserted at the top of the dictation.  The radiologist then dictates a report which consists of only pertinent positive and pertinent negative findings.  Each finding is placed on a line by itself to aid in report processing.  The order of the findings is not important.  The use of macros is allowed but not required.  No negative findings are dictated unless they are pertinent negative findings. The radiologist uses two simple keywords while dictating.  If no keyword is inserted at the end of a finding, the finding is considered incidental and not included in the impression.  Otherwise the finding is either copied into the impression or new text is dictated for the impression which pertains to this finding.  In this way, the finding section and impression section are created simultaneously. Once the brief, keyword-encoded report is dictated, the software processes the dictation on a line-by-line basis using anatomic queues to determine if the finding belongs to a particular organ system.  The best practices radiology report templates provided by the RSNA Radiology Reporting Initiative are used to create the structure of the report and the RadLex lexicon is followed for any non-dictated normal findings which are automatically inserted.  An error check is performed on the final report and the radiologist is warned if a possible error is found (such as laterality errors) or if the report does not contain certain reporting requirements.

The ratio of dictated text to the text present in the final report (D/R ratio) is less than 50% for most reports.  For reports with few or no pertinent findings the D/R ratio is less than 10%.  This reduces dictation effort and increases report quality through the creation of standardized and itemized reports.

The software described significantly increases radiologist efficiency and report quality and is compatible with almost any speech recognition or word processing application.

High quality standardized and itemized reports can be created without decreasing radiologist efficiency or distracting them from the review of images.

Stewart, J, Rapid Creation of a Structured and Itemized Radiology Report from a Brief and Disorganized Dictation.  Radiological Society of North America 2013 Scientific Assembly and Annual Meeting, December 1 - December 6, 2013 ,Chicago IL. http://archive.rsna.org/2013/13019941.html