RESUMO
CLINICAL ISSUE: Structured reporting has been one of the most discussed topics in radiology for years. Currently, there is a lack of user-friendly software solutions that are integrated into the IT infrastructure of hospitals and practices to allow efficient data entry. STANDARD RADIOLOGICAL METHODS: Radiological reports are mostly generated as free text documents, either dictated via speech recognition systems or typed. In addition, text components are used to create reports of normal findings that can be further edited and complemented by free text. METHODOLOGICAL INNOVATIONS: Software-based reporting systems can combine speech recognition systems with radiological reporting templates in the form of interactive decision trees. A technical integration into RIS ("radiological information system"), PACS ("picture archiving and communication system"), and AV ("advanced visualization") systems via application programming interfaces and interoperability standards can enable efficient processes and the generation of machine-readable report data. PERFORMANCE: Structured and semantically annotated clinical data collected via the reporting system are immediately available for epidemiological data analysis and continuous AI training. EVALUATION: The use of structured reporting in routine radiological diagnostics involves an initial transition phase. A successful implementation further requires close integration of the technical infrastructure of several systems. PRACTICAL RECOMMENDATIONS: By using a hybrid reporting solution, radiological reports with different levels of structure can be generated. Clinical questions or procedural information can be semi-automatically transferred, thereby eliminating avoidable errors and increasing productivity.
