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Der Nuklearmediziner 2017; 40(04): 285-290
DOI: 10.1055/s-0043-111359
Basiswissen Nuklearmedizin
© Georg Thieme Verlag KG Stuttgart · New York

Strukturierte Befundung in der Nuklearmedizin

Structured reporting in nuclear medicine
Matthias F. Froelich
1   Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, München
,
Stefan Dresel
2   Klinik für Nuklearmedizin, HELIOS Klinikum Berlin-Buch, Berlin
,
Andrei Todica
3   Klinik und Poliklinik für Nuklearmedizin, Klinikum der Universität München, Ludwig-Maximilians-Universität München, München
,
Wieland H. Sommer
1   Klinik und Poliklinik für Radiologie, Klinikum der Universität München, Ludwig-Maximilians-Universität München, München
› Author Affiliations
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Publication History

Publication Date:
04 December 2017 (online)

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Zusammenfassung

Der medizinische Befundbericht als zentrales Kommunikationsmittel zwischen Ärzten wird traditionell als Freitext formuliert. Im Rahmen der zunehmenden strukturiert geplanten Abläufe in der Medizin (z. B. SOP-Entwicklungen, grundsätzliche Therapieentscheidungen in Tumorboards) wird die Praxis der Freitextbefundung durch Initiativen zur strukturierten Befundung in Frage gestellt.

Als Hauptargumente für eine zunehmende Befundstrukturierung werden Vollständigkeit, linguistische Qualität, Überweiserzufriedenheit, inhaltliche Struktur, bessere Wahrnehmbarkeit der wichtigen Befundergebnisse und daraus folgend bessere klinische Therapieentscheidungen angeführt. Zusätzlich ergeben sich deutliche Verbesserungen in Bezug auf die gesamte klinische Arbeitskette. Demgegenüber stehen Bedenken in Bezug auf Effizienz und Individualisierbarkeit und es zeigen sich gerade bei erfahrenen Befundern Hürden hinsichtlich der Anpassung an vorgegebene Befundstrukturen.

Moderne, computergestützte Systeme zur strukturierten Befundung haben das Potenzial die Vorteile strukturierter Befunde bei Erhaltung von Individualisierbarkeit und Arbeitseffizienz zu realisieren.

Abstract

Medical communication in reports has traditionally been focused on free text reports. However, the free text report is challenged by an increasing trend of structured planning and decision making in medicine (for example SOP implementation, tumor boards).

Often mentioned advantages of structured reports include completeness, linguistic quality, referring physician satisfaction, content structuring, better emphasis on important findings and, as a result, better clinical therapy decision making. Furthermore, momentous improvements in the whole workflow can be realized. Yet, lack of efficiency and customizability – especially for experienced reporting physicians – are often mentioned counterarguments.

Modern, computer-aided diagnostic systems for structured reporting have the potential to leverage the advantages of structured reports while maintaining customizability and efficiency.

Schlüsselwörter

Strukturierte Befundung - Befundungsvorlagen - Checklisten - Standardisierung

Keywords

Structured Reporting - Reporting Templates - Checklists - Standardization
 

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