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

Academic Article

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.
  • Digital Object Identifier (doi)

    Author List

  • McFarland JA; Elkassem AMA; Casals L; Smith GD; Smith AD; Gunn AJ
  • Start Page

  • 387
  • End Page

  • 393
  • Volume

  • 46
  • Issue

  • 1