加强并完善超声医学住院医师规范化培训中的报告书写

Strengthening and improving report writing during standardized training of residents of ultrasonic medicine

超声检查报告(超声报告)所反映的是超声医师根据声像图及患者的临床情况进行综合分析、判断后所获得的总结性信息,是超声医师参与临床诊疗过程的重要劳动成果。尽管超声报告的重要性显而易见,但在进行超声医学住院医师规范化培训的过程中,住院医师在报告书写方面往往未能受到足够的专门训练。在进行书写超声所见、诊断及建议时可遵循一定的原则,从而提高报告质量,改善阅读体验。超声所见应包括简洁但全面、客观的描述,避免重复。诊断部分不是简单重复超声所见,而是通过总结归纳后获得简洁明了、容易理解的诊断和鉴别诊断,并为患者下一步诊疗方案指明方向。超声医师通过持续不断的学习、随访、总结,才能够提高超声报告的书写水平。

The ultrasound diagnosis imaging report reflects the sum of a radiologist′s synthesis and judgement into a patient′s condition.It is also an important product that is generated by radiologists to help the patients.In spite of the importance of clear and effective report writing,radiologists usually receive little or no formal reporting education.There are key principles when reporting the ultrasound findings,impression,and recommendations to promote report quality and reading experience.The findings should emphasize short and factual observations while avoiding redundancy.The impression is the thoughtful synthesis of findings leading to a diagnosis,a differential diagnosis and management recommendations.Improved report writing is achieved only after persistent learning,follow up and summaries.