Radiology reports are essential for documenting and sharing a physician's findings. There are many ways of formatting these reports. This blog explores the difference between two that are often confused as the same thing but are fundamentally different. Knowing the difference between these two types of reports is essential when talking to your cloud PACS vendor.
In radiology, most reports are written as free text narratives. The free narrative reports are inconsistently formatted, may omit important data, and are difficult to read. To combat the irregularity of these reports, radiologists are beginning to introduce structured reporting.
As the name suggests, structured reporting is the documentation methodology for clinical practices which captures and displays specific data elements in a specific format. These reports offer standardization of information, ease of understanding, and save time dictating and editing free narrative reports.
Structured reporting provides saved templates that capture and display information in a clear and concise format. Each template has its own predetermined report format along with terms. The format and terms help ensure that data is promptly entered with all necessary data elements and allows for scalable data capture.
A basic example of what a structured format may look like is shown below. These structured reports include a header followed by a report title. Then it includes the patient demographic information, pulled from the metadata. The text boxes are customizable but can include the 'exam data', 'clinical Information', 'findings', and the 'conclusion'. Within this template structure, the results are displayed in a clear and concise manner. It is an easier report for patients and referring physicians to look through and understand.
The Purview platform also features key images, meaning the reports can include the images most pertinent to the findings.
DICOM Structured Reporting
When talking to your cloud vendors, they might ask if you use or will require DICOM structured reporting (DICOM SR). This style is entirely different from the customizable, templated structured reporting mentioned above.
DICOM SR is the standard for the exchange of data in the imaging environment. In other words, it is accessible within the viewer, not outside of it, and is primarily used internally as opposed to shared out to patients and other physicians. The information in DICOM SR includes structured data or clinical observations, along with the patient information. It is still a standardized report containing pertinent patient information, however, it is only accessible within the viewer.
In order to operate within the imaging infrastructures and toolkits, DICOM SR is constrained by templates and SOP Classes to improve interoperability. If this is a feature you are interested in or that your practice requires, make sure to check in with your cloud vendor. DICOM SR will often be accessible in a similar way as the video below, note that it lives inside the viewer and contains a structured report of the patient.