RESUMO
PURPOSE: This study aimed to determine whether structured reports (SRs) reduce reporting time and/or increase the level of detail for trauma CT scans compared to free-text reports (FTRs). METHOD: Eight radiology residents used SRs and FTRs to describe 14 whole-body CT scans of patients with polytrauma in a simulated emergency room setting. Each resident created both a brief report and a detailed report for each case using one of the two formats. We measured the time to complete the detailed reports and established a scoring system to objectively measure report completeness and the level of detail. Scoring sheets divided the CT findings into main and secondary criteria. Finally, the radiological residents completed a questionnaire on their opinions of the SRs and FTRs. RESULTS: The detailed SRs were completed significantly faster than the detailed FTRs (mean 19 min vs. 25 min; p < 0.001). The maximum allowance of 25 min was used for 25% of SRs and 59% of FTRs. For brief reports, the SRs contained more secondary criteria than the FTRs (p = 0.001), but no significant differences were detected in main criteria. Study participants rated their own SRs as significantly more time-efficient, concise, and clearly structured compared to the FTRs. However, SRs and FTRs were rated similarly for quality, accuracy, and completeness. CONCLUSION: We found that SRs for whole-body trauma CT add clinical value compared to FTRs because SRs reduce reporting time and increase the level of detail for trauma CT scans.
