Evolution of Radiology Reporting FINAL · unremarkable. The pancreas as visualized is normal. The...
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EVOLUTION OF RADIOLOGY REPORTING Traditional Handwritten Report CONS: • Difficult to read • No images • No patient history • Slow turnaround time TRANSCRIBED VIA VOICE RECOGNITION Transcribed Report PROS: • Easy to read • Standardized format • Consistent templat CONS: •More steps in the proce • Text only • No way to compare to priors • No patient history PROS: • Faster turn around • Saves workflow steps • Easy to read • Structured report CONS: • Text only, no images • No way to compare to priors • No patient history Midland Imaging Name: Patient ID: History: Date of Birth: Study CT chest with contrast Facility: Physician: XXXXX XXXXXX, MD Date of Service: XX/XX/XXXX XX:XX:XX PROCEDURE: CT chest with contrast REASON FOR EXAM: Female, 59 years old. Congestion and a left upper lobe infiltrate. RADIATION DOSAGE: (if Supplied by Facility): CTDlvol=(30.34) mGy, DLP=(523.87) mGycm. TECHNIQUE: High resolution transaxial imaging was preformed following intravenous administration of 100ml of Isovue 300 contrast material. Multi planar coronal and sagittal images were reformatted. COMPARISON: Prior CT scan 02/20/13 and radiographs 02/26/13 PROS: • Key data for holistic patient view • Patient history • Hyperlinks to images and reports from other modalities MULTIMEDIA REPORT PROCEDURE: CT Abdomen with contrast CLINICAL INDICATION: Liver metastases (unknown primary tumor). TECHNIQUE: CT scan of the abdomen with and without contrast was performed ont he volumetric 64 slice CT scanner. The patient was scanned following the uncomplicated intravenous administration of 100 cc of Omnipaque 300. 3-D coronal reformatted images were obtained from the axial source images. COMPARISON: None FINDINGS: The lung bases are clear. The heart size is normal, without pericardial thickening or effusion. There are several hypodense lesions on both lobes of the liver the largest with a diameter of 54.00 mm that represent liver metastasis from unknown origin most probably. The spleen is normal in size and homogeneous in density. The stomach is partially collapsed, but is grossly unremarkable. The pancreas as visualized is normal. The gallbladder and biliary tree are unremarkable and there is no evidence for biliary dilatation. The adrenal glands are symmetric and normal. The kidneys are symmetrically unremarkable as well. The collecting system on the right is enlarged. The aorta is of normal caliber. Aortic calcifications are present. There is no retroperitoneal lymphadenopathy. The porta hepatis region is clear. The bowel and mesentery, as visualized, are equally unremarkable. S/P total left hip replacement. The surrounding osseous structures are remarkable for mild degenerative spondylosis of the spine. Mild scoliosis of the lumbar spine No osteolytic or osteoblastic lesion is detected. IMPRESSION: 1. Several liver metastasis on both lobes from unknown origin. 2. S/P total left hip replacement Name: KING KEVIN ID: 201222091934 Accession No.: 9275000235689 Report Date: 23/12/2005 Referring Physician: David Evans, MD 713-213-5479 [email protected] Report Information Midland Imaging • Results from prior exams for comparisons of progress • Quantitative analysis as graphs and charts for easy data interpretation • Short-cut links to other patient data and records • Hi-res images embedded in report • All-inclusive data and findings • Interactive • Automatic display of priors for visual of progress KING KEVIN 71Y3MM201222091934 Series Desc KEY_IMAGES FR Generated from 5861-73 <5862-1 (KEY)> Midland Imaging [23/12/2005.0:57:37] Current SW300mm carestream.com/vue-reporting PROCEDURE: CT Chest. CLINICAL INDICATION: Known left-sided squamous cell carcinoma of the lung post surgery with suspected lung metastsis TECHNIQUE: CT scan of the chest without contrast was performed on the GE volumetric 64 slice CT scanner. 3-D coronal reformatted images were obtained from the axial source images. COMPARISON: CT March 31 2012, CT June 23 2012 Name: DAVIS DOROTHY ID: 201201061940 Accession No.: 9275000234567 Report Date: 28/09/2012 Referring Physician: David Evans, MD 713-213-5479 [email protected] Report Information 450 400 350 300 250 200 150 100 50 0 F05 F04 F07 Volume 31/03/2012 Baseline 28/09/2012 Followup 07/08/2012 Date 23/06/2012 Followup Target Lesions Name Target Description Series Image Long Diameter (mm) Short Diameter (mm) Volume (mm 3 ) SUV Max (BW) B06 (F04) Target Lesion (Lung) 3 99 13 5.4 407.8 -- B08 (F07) Target Lesion (Lung) 3 63 12.8 8.3 437.9 -- B07 (F05) Target Lesion (Lung) 3 71 7.9 5.7 228.1 -- Sum of target lesions (3): 33.7mm (Long) The automatic segmented lesions may not have been approved or adjusted Change Over Time Name Target Baseline 2012-03-31 2012-06-23 2012-09-28 (Current) F05 Target Volume (mm 3 ) Long (mm) Short (mm) 109.4 (--) 7.1 (--) 3.5 (--) 165.4 (+51.2%) 7.3 (+4%) 5.1 (+43.9%) 140 228.1 (+108.5%) 7.9 (+12.2%) 5.7 (+62.6%) 170 Midland Imaging 2005-12-23, CT Abdomen Study Information Name Target Description Series Image Long Diameter (mm) Short Diameter (mm) Volume (mm3) SUV Max (BW) Other Lesions Signed By John Jennings, MD B01 Lesion (Liver) 5861 72 34.8 25.4 8888.7 -- B02 Lesion (Liver) 5861 67 54 44.7 49936.2 -- The automatic segmented lesions may not have been approved or adjusted. Midland Imaging [23/12/2005.0:57:37] Current SW300mm
Transcript of Evolution of Radiology Reporting FINAL · unremarkable. The pancreas as visualized is normal. The...
EVOLUTIONOF RADIOLOGY
REPORTING
Traditional Handwritten ReportCONS:• Difficult to read• No images• No patient history• Slow turnaround time
TRANSCRIBED VIAVOICE RECOGNITION
Midland Imaging
Transcribed Report
PROS:• Easy to read• Standardized format• Consistent templatee
CONS:•More steps in the process• Text only• No way to compare to priors• No patient history
P R O S :• Faster turn around • Saves work�ow steps• Easy to read• Structured report
C O N S :• Text only, no images• No way to compare to priors• No patient history
Midland Imaging
Name:Patient ID:History:Date of Birth:Study CT chest with contrastFacility:Physician: XXXXX XXXXXX, MDDate of Service: XX/XX/XXXX XX:XX:XX
PROCEDURE: CT chest with contrast
REASON FOR EXAM: Female, 59 years old. Congestion and a left upper lobe in�ltrate.
RADIATION DOSAGE: (if Supplied by Facility): CTDlvol=(30.34) mGy, DLP=(523.87) mGycm.
TECHNIQUE: High resolution transaxial imaging was preformed following intravenous administration of 100ml ofIsovue 300 contrast material. Multi planar coronal and sagittal images were reformatted.
COMPARISON: Prior CT scan 02/20/13 and radiographs 02/26/13
P R O S :• Key data for holistic patient view • Patient history• Hyperlinks to images and reports from other modalities
M U L T I M E D I A
REPORT
PROCEDURE: CT Abdomen with contrast
CLINICAL INDICATION: Liver metastases (unknown primary tumor).
TECHNIQUE: CT scan of the abdomen with and without contrast was performed ont he volumetric 64 sliceCT scanner. The patient was scanned following the uncomplicated intravenous administration of 100 cc ofOmnipaque 300. 3-D coronal reformatted images were obtained from the axial source images.
COMPARISON: None
FINDINGS: The lung bases are clear. The heart size is normal, without pericardial thickening or effusion.There are several hypodense lesions on both lobes of the liver the largest with a diameter of 54.00 mm thatrepresent liver metastasis from unknown origin most probably.The spleen is normal in size and homogeneous in density. The stomach is partially collapsed, but is grosslyunremarkable. The pancreas as visualized is normal. The gallbladder and biliary tree are unremarkable andthere is no evidence for biliary dilatation. The adrenal glands are symmetric and normal.The kidneys are symmetrically unremarkable as well. The collecting system on the right is enlarged.The aorta is of normal caliber. Aortic calci�cations are present. There is no retroperitoneallymphadenopathy. The porta hepatis region is clear. The bowel and mesentery, as visualized, are equallyunremarkable.S/P total left hip replacement.The surrounding osseous structures are remarkable for mild degenerative spondylosis of the spine. Mildscoliosis of the lumbar spine No osteolytic or osteoblastic lesion is detected.
IMPRESSION:1. Several liver metastasis on both lobes from unknown origin.2. S/P total left hip replacement
Name: KING KEVIN ID: 201222091934Accession No.: 9275000235689 Report Date: 23/12/2005
Referring Physician: David Evans, MD 713-213-5479 [email protected]
Report Information
Midland Imaging
• Results from prior exams for comparisons of progress• Quantitative analysis as graphs and charts for easy data interpretation • Short-cut links to other patient data and records
• Hi-res images embedded in report• All-inclusive data and findings • Interactive• Automatic display of priors for visual of progress
KING KEVIN71Y3MM201222091934Series Desc KEY_IMAGES FRGenerated from 5861-73<5862-1 (KEY)>
Midland Imaging[23/12/2005.0:57:37]CurrentSW300mm
carestream.com/vue-reporting
PROCEDURE: CT Chest.
CLINICAL INDICATION: Known left-sided squamous cell carcinoma of the lung post surgery with suspectedlung metastsis
TECHNIQUE: CT scan of the chest without contrast was performed on the GE volumetric 64 slice CT scanner.3-D coronal reformatted images were obtained from the axial source images.
COMPARISON: CT March 31 2012, CT June 23 2012
Name: DAVIS DOROTHY ID: 201201061940Accession No.: 9275000234567 Report Date: 28/09/2012
Referring Physician: David Evans, MD 713-213-5479 [email protected]
Report Information
450
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100
50
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F05 F04 F07
Volu
me
31/03/2012Baseline
28/09/2012Followup
07/08/2012
Date
23/06/2012Followup
Target LesionsName Target Description SeriesImageLong Diameter (mm)Short Diameter (mm)Volume (mm3)SUV Max (BW)
B06 (F04) Target Lesion (Lung) 3 99 13 5.4 407.8 --
B08 (F07) Target Lesion (Lung) 3 63 12.8 8.3 437.9 --
B07 (F05) Target Lesion (Lung) 3 71 7.9 5.7 228.1 --
Sum of target lesions (3): 33.7mm (Long)The automatic segmented lesions may not have been approved or adjusted
Change Over TimeName Target Baseline
2012-03-312012-06-23 2012-09-28 (Current)
F05 Target Volume (mm3)
Long (mm)
Short (mm)
109.4 (--)
7.1 (--)
3.5 (--)
165.4 (+51.2%)
7.3 (+4%)
5.1 (+43.9%)
140
228.1 (+108.5%)
7.9 (+12.2%)
5.7 (+62.6%)
170
Midland Imaging
2005-12-23, CT Abdomen
Study Information
Name Target Description Series Image Long Diameter (mm) Short Diameter (mm) Volume (mm3) SUV Max (BW)
Other Lesions
Signed ByJohn Jennings, MD
B01 Lesion (Liver) 5861 72 34.8 25.4 8888.7 --
B02 Lesion (Liver) 5861 67 54 44.7 49936.2 --
The automatic segmented lesions may not have been approved or adjusted.
Midland Imaging
[23/12/2005.0:57:37]
CurrentSW300mm
