A Diagnostic Electronic Reporting Framework Proposal Using Preassigned Automated Coded Phrases

Abstract

Radiologists daily diagnose a large number of Chest X-rays and it is crucial that these reports are appropriately recorded, meaningfully indexed, carefully stored, easily retrieved, shared and printed. The absence of organized reports’ storage does not permit their direct and easy retrieval, while after almost a year the report is perished and not even readable (handwritten or typed). The scope of this paper is to evaluate and propose the use of preassigned automated-coded phrases for the chest X-ray electronic reporting in a Radiology Department. The research included 9,252 typed reports, using the proposed method and 949 hand written reports (later typed or not), which were used to compare between the time being spent in reporting with either method. The results proved that even if the method could not be applied fully, there was a 90% reduction of the time being spent by the radiologists and secretarial staff in a Radiology Department, thereby facilitating the typing and management of the electronic archives. In addition, it was found that the reprinting due to addendums/discrepancies, when the proposed method was used, was reduced fourfold, when compared to the previously used methods. In conclusion, the consistent application of preassigned automated-coded reporting can be time saving, cost effective and environmentally friendly saving paper and ink.