The clinical report is an essential part of the service you provide to your patients. As a tool that communicates information to the referring physicians, records that information for future use, and serves as the legal record that documents the episode of care-it is of utmost importance that the report be uniform, comprehensive and easily managed. To take full advantage of the benefits information technology provides in medicine, radiology reports must also be "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 report templates are "structured" in the sense that they incorporate reusable knowledge, or meaning, to the clinical reporting process. They 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 create software products that enable radiologists to create high-quality radiology reports more efficiently.
Supported in part by the National Institute of Biomedical Imaging and Bioengineering (NIBIB).