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Befundkommunikation

Image interpretation and the radiological report

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Zusammenfassung

Hintergrund

Der radiologische Befund ist das zentrale Medium, über das der Radiologe mit dem Zuweiser und Patienten kommuniziert. Er besteht im Wesentlichen aus zwei Komponenten: der Interpretation von Bildstudien und der Kommunikation dieser Interpretation.

Ziel der Arbeit und Methoden

Im vorliegenden Artikel werden verschiedene Arten der Kommunikation des radiologischen Befunds erläutert. Darüber hinaus werden Anforderungen an dessen Inhalt und Struktur beleuchtet. Hierzu werden aktuelle Empfehlungen von nationalen und internationalen Fachgesellschaften zusammengefasst und klinische Anwendungsbeispiele präsentiert.

Ergebnisse

Die häufigste Kommunikationsform ist der schriftliche Befund als (Prosa‑)Text, der in Qualität, Präzision und Struktur sehr individuell ist. Um ein besseres Verständnis des Geschriebenen zu erreichen, kann der Befund z. B. durch zusätzlich erzeugtes Bildmaterial ergänzt werden (sog. „multimedia-enhanced reporting“). Mit dem Ziel, eine zunehmende Standardisierung zu erreichen, wird die strukturierte Befundung von zahlreichen Fachgesellschaften als die zu präferierende Befundungsart empfohlen, konnte sich jedoch bislang nicht flächendeckend in der Praxis durchsetzen.

Schlussfolgerung

Eine effektive Befundkommunikation sollte das weitere Patientenmanagement unterstützen, zeitnah erfolgen und frei von Unklarheiten sein. Die optimale Befundkommunikation wird im klinischen Alltag allerdings durch viele Faktoren erschwert. Deshalb sollten interdisziplinär interne Standards definiert werden, um optimierte Kommunikations-Workflows etablieren zu können.

Abstract

Background

The radiological report is the cornerstone of communication between radiologists and referring physicians and patients, respectively. The report is comprised of image interpretation on the one hand and communication of this interpretation on the other hand.

Objectives and methods

To outline different types of radiological reports (regarding content as well as structure) and their communication. To this end, current guidelines are summarized and clinical examples are presented.

Results

The radiological report is typically a written piece of free text prose and highly individualized regarding its quality, precision, and structure. In order to improve the understanding of the written report, additional material (e.g., annotations, images, tables) can be supplemented (multimedia-enhanced reporting). In terms of standardization, national and international radiological associations promote structured reporting in radiology. However, this is not without issues.

Conclusion

Effective communication should improve patient care and it should be clear and provided in a timely manner. As communication in clinical reality is often hampered by various factors, internal standard operating procedures (SOPs) should be developed to improve communication workflows.

to improve communication procedures.

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Authors and Affiliations

  1. Klinik und Poliklinik für Diagnostische und Interventionelle Radiologie, Universitätsmedizin Mainz, Langenbeckstraße 1, 55131, Mainz, Deutschland

    Fabian Stoehr, Peter Mildenberger & Tobias Jorg

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  1. Fabian Stoehr
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Correspondence to Fabian Stoehr.

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Interessenkonflikt

F. Stöhr, P. Mildenberger und T. Jorg geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Stoehr, F., Mildenberger, P. & Jorg, T. Befundkommunikation. Radiologie 63, 110–114 (2023). https://doi.org/10.1007/s00117-023-01122-x

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