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Structured Reporting of IR Procedures: Effect on Report Compliance, Accuracy, and Satisfaction

Published:January 18, 2018DOI:https://doi.org/10.1016/j.jvir.2017.10.016

      Abstract

      Purpose

      To compare effect of free-text versus structured reporting of IR procedures on report quality and report coding and value.

      Materials and Methods

      In this retrospective study, 432 common consecutive free-text IR reports created during 4 months (from September 2013 to December 2013) before implementation of structured reporting (February 2014) and 415 structured IR reports created after implementation (from September 2014 to December 2014) were reviewed to assess ease of use and compliance with reporting requirements for regulatory requirements and coding. IR staff and trainees and referring physicians to IR were surveyed on procedure report attributes, such as detail, quality, and clarity.

      Results

      Structured reporting increased compliance with reporting fluoroscopy time, radiation dose, and contrast administration compared with free-text reports (402/432 [93.1%] vs 251/415 [60.5%], P < .001; 402/432 [93.1%] vs 242/415 [58.3%], P < .001; and 395/432 [91.4%] vs 257/415 [61.9%], P < .001). Structured reporting decreased addendum requests for insufficient documentation from 43% (121/435 [28%] to 50/415 [12%], P = .01). Most IR physicians found structured reports to require less time to complete (21/26 [81%]), to be easier to complete (23/26 [89%]), and to have a similar or higher level of detail (19/26 [73%]) compared with free-text reports. Referring physicians were more satisfied with structured reports compared with free-text reports (6.9/10 vs 5.6/10, P = .03).

      Conclusions

      Structured IR reporting compared with free-text reporting improves compliance with radiation dose and contrast reporting, reporting and coding efficiency, and satisfaction among IR and referring physicians.

      Abbreviations:

      ACR (American College of Radiology), CPT (Current Procedural Terminology), RVU (relative value unit)
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