Difference between revisions of "Report template guidelines"

From RSNA Radiology Reporting Initiative
Jump to navigation Jump to search
Line 3: Line 3:
 
* Except for report headings, users are able to enter "free" (unstructured, narrative) text anywhere in a report.  Any field for structured data can be filled with plain text.
 
* Except for report headings, users are able to enter "free" (unstructured, narrative) text anywhere in a report.  Any field for structured data can be filled with plain text.
  
 +
* Any data item has "built-in" modifiers to specify:
 +
** Degree of certainty [definite | probable | ...]
 +
** Criticality
 +
** Change [unchanged | decreased | increased]
  
 
== Template overview ==
 
== Template overview ==

Revision as of 18:40, 28 May 2009

General principles

  • Except for report headings, users are able to enter "free" (unstructured, narrative) text anywhere in a report. Any field for structured data can be filled with plain text.
  • Any data item has "built-in" modifiers to specify:
    • Degree of certainty [definite | probable | ...]
    • Criticality
    • Change [unchanged | decreased | increased]

Template overview

  • Text fields are enclosed by square brackets. A default value may be shown.
    Lungs:  [Normal.]
  • Single-choice items are separated by vertical bars ("pipes") within square brackets. An asterisk indicates the default value.
    Hydronephrosis: [None* | Mild | Moderate | Severe]
  • Multiple-choice items are indicated by semicolons within square brackets.
    Indications: [chronic chest pain; atypical angina; pre-valve replacement]
  • Numeric values are indicated by the "#" sign. Units may be indicated.
    Contrast dose: [# mL]
  • Pre-defined data types are specified within angle brackets. These data types might include specific types of data or values that might flow into the reporting system from acquistion devices.
    Date: [<date>]
    Head Circumference: [<ultrasound:hc>]
  • Comments are indicated by curly braces.
    {If left or co-dominant: LPDA and LPL branches should be addressed.}