During the softcopy reading of an imaging study, the physician dictates the report, which is sent to a transcription service or is processed by a voice recognition system. The transcribed dictation arrives at the report management system (typically a RIS) by some mechanism not specified here. The report management system enables the reporting physician to correct, verify, and “sign” the transcribed report. See Figure X.1-1. This data flow applies to reports stored in a proprietary format, reports stored as DICOM Basic Text SR SOP Instances, or reports stored as HL7 CDA instances.
Figure X.1-1 Dictation/Transcription Reporting Data Flow
The report management system has flexibility in encoding the report title. For example, it could be any of the following:
the generic title “Diagnostic Imaging Report”,
a report title associated with the department (e.g., “Radiology Report”),
a report title associated with the imaging modality or procedure (e.g., “Ultrasound Report”), or
a report title pre-coordinated with the modality and body part (e.g., “CT Chest Report”).
There are LOINC codes associated with each of these types of titles, if a coded title is used on the report (see PS3.16 CID 7000).
The transcribed dictation may be either a single text stream, or a series of text sections each with a title. Division of reports into a limited number of canonically named sections may be done by the transcriptionist, or automated division of typical free text reports may be possible with voice recognition or a natural language processing algorithm.
For an electronically stored report, the signing function may or may not involve a cryptographic digital signature; any such cryptographic signature is beyond the scope of this description.