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Published in: Abdominal Radiology 1/2021

01-01-2021 | Computed Tomography | Practice

Objective comparison of errors and report length between structured and freeform abdominopelvic computed tomography reports

Authors: J. Alex McFarland, Asser M. Abou Elkassem, Luke Casals, Grant D. Smith, Andrew D. Smith, Andrew J. Gunn

Published in: Abdominal Radiology | Issue 1/2021

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Abstract

Purpose

To objectively compare structured and freeform abdominopelvic CT reports based on the number and types of errors as well as report length.

Methods

90 structured and 89 freeform reports from abdominopelvic CT scans with IV contrast obtained for the indication of abdominal pain were randomly selected for review. Each report was reviewed for errors, which were counted and categorized based on the type of error. The total number of words in each report was tallied.

Results

105 total errors were found in the structured reports, compared to 157 total errors in freeform reports. There were 1.16 errors per structured report and 1.76 errors per freeform report (p < 0.001). 48% of structured reports contained at least one error, while 71% of freeform reports contained at least one error (p = 0.002). When a difference existed between the styles with regard to error categories, more errors were observed in freeform reports, with the exception of the duplicated period error where structured reports had more errors. No difference on the basis of average words per report existed, with 219.2 words per report for each reporting style.

Conclusion

The use of structured reporting for abdominopelvic CT results in less errors in the report when compared to freeform reporting, potentially reducing clinically significant adverse outcomes in patient care. The report length on the basis of number of words per report is not different between the two reporting styles.
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Metadata
Title
Objective comparison of errors and report length between structured and freeform abdominopelvic computed tomography reports
Authors
J. Alex McFarland
Asser M. Abou Elkassem
Luke Casals
Grant D. Smith
Andrew D. Smith
Andrew J. Gunn
Publication date
01-01-2021
Publisher
Springer US
Published in
Abdominal Radiology / Issue 1/2021
Print ISSN: 2366-004X
Electronic ISSN: 2366-0058
DOI
https://doi.org/10.1007/s00261-020-02646-9

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