Structured Report Page

In our system architecture model, a structured report page similar to what have been de- veloped by previous works was included. The main difference between the structured report page that we have developed and the ones used in previous ultrasound reporting systems is that ours was designed with much more flexibility and less rigidity. The structured report page was also designed according to the quality criteria guidelines as provided in Appendix A. These guidelines were developed based on suggestions from literatures and specifications created by the Society and College of Radiographers and British Medical Ultrasound Society [64] as well as the United Kingdom Association of Sonographers [66].

It is recommended that the ultrasound report be presented in a tabulated or itemised format [19, 22, 69] by separating the report with suitable headings. The report should include basic information about the patient such as his name, age and gender as well as the radiologist such as his name and status and the location of the examination [41, 66]. It should also include the patient’s clinical history including the reason for referral if available [41]. Following this, several text fields and a radio button have been included to accommodate all of this information as seen in Figure 3.5.

Figure 3.5: Basic information and clinical history fields

the patients’ information as this will be included automatically by the system. This reduces the need for the radiologists to key in a lot of data and allow them to focus on the findings of the examination instead. The structured report page automatically records the time when the report is written and when the radiologists sign off the report. Information such as this is important in assessing the turn around time of a report. It can also be refered to whenever there are any medical legal issues.

When submitting the form, it will validate whether the basic information has been provided. If not, the form will not be allowed to submit. However, if the clinical history field has been left blank for example, the system will remind the radiologists to complete it in once. If the field has been left blank for the second time, the system will allow the form to be submitted since sometimes there is no clinical history available. It is important that the form be flexible because there are times where not all information is available to the radiologists. If the form does not allow them to submit until all fields are completed, they might not be able to submit the report at all.

The ultrasound report should include all relevant areas including both examined and not examined areas [22, 66]. If the relevant areas have not been examined, the reason for it should be stated [66]. To ensure that flexibility is given to the radiologists in completing the report, they have the option to add or remove fields when reporting the relevant areas (see Figure 3.6). All findings and observations should be reported

Figure 3.6: Fields for relevant areas and observations / findings

and classified as either normal or abnormal whether it is expected or not [66]. The discussion and the survey conducted during UKRC 2015 has prompted us to design a table as displayed in Figure 3.6 where findings are separated by areas and can be classified as “normal”, “abnormal” or “inconclusive”. When selecting the “normal” checkbox, the radiologists have a further option to indicate whether it is a normal variant. If the radiologists select “abnormal”, they can then indicate if it is an incidental finding. The discussion and reasoning that has led to this design will be elaborated further in Section 3.4.2.

The reason that the radiologists are given the option to classify their findings is to make their report more meaningful. Edwards, Smith and Weston [22] have suggested that radiologists should avoid measurements in their reports unless it is stated whether the measurement is normal or abnormal. The rows in the “findings / observations” table can also be added or removed based on the number of areas that the radiologists have examined. The structured form also includes a field for the radiologists to give a conclusion to the report that answers the clinical question. It also includes a field for the radiologists to suggest any further examinations. The complete structured form interface is displayed in Figure C.6 in Appendix C.

Though this structured report form still requires a lot of mouse control and click- ing, the radiologists will always have the option of using the free-form report if they find it hard to use the structured form. However, if they choose to use the structured report form, the benefits are that it would help guide the radiologists in giving enough information about the ultrasound examination and ensure that the report they produced will be of good quality. This reduces the probability of them needing to edit the report to conform to the quality guidelines.