The key to success was consensus, achieved by having all members of the radiology department participate in the process of creating the reports. A second important factor was identifying a reasonable goal: creating exam-specific normal reports for all studies and common abnormal reports.
Rebecca Pryor, radiology compliance and education specialist at Cincinnati Children's , will discuss this initiative. In brief, a work group consisting of radiologists, section leaders, and administrative staff was formed. Members of the work group were asked to create content for the most commonly dictated studies in their division.
Each structured report that was developed included a description of normal findings preferred by most clinicians and pertinent negative findings referring to the most common and/or important clinical questions. Fields to fill in for the most common abnormal diagnoses were created. In addition to an agreed-upon general format, the report templates were designed to require either no or minimal removal of statements for a normal exam, and no or minimal data entry. They also could be easily changed when reporting abnormal exams.
An executive committee reviewed the reports to standardize phraseology and verify that all elements required for reimbursement were included. After editing, as needed, these reports were then reviewed by the department faculty, with any additional changes made and rereviewed.
Once a report template was adopted, it was tied to a specific RIS exam code and entered into the speech recognition dictation system. When a radiologist dictates the RIS exam code, the template is launched.
As of March 2011, a total of 178 report templates had been developed.