Strukturierte Befundung
Structured reporting, sometimes called synoptic reporting, is a method of clinical documentation that captures and displays specific data elements in a specific format. In radiology, the majority of reports are free text narratives, which are variably formatted and prone to the omission of important data. In contrast, structured reporting templates provide consistency and clarity, prompt entry of all necessary data elements, and is amenable to scalable data capture, interoperability, and exchange .
Most published examples of structured reporting templates are based on the technique and body part examined. A variant known as contextual reporting provides fields relevant to the disease or examination indication .
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