| 英文摘要 |
Objective：The main objective of this project is to introduce structured reporting by transforming descriptive reports into structured data, thereby constructing standardized medical report templates.
Methods：The project is carried out through team collaboration, involving: (1)inviting leaders in departments that have successfully implemented structured reporting to share their experiences. (2)formulating the standard elements of structured reporting. (3)establishing the timeline for implementing structured reporting. (4)developing the functionalities of the structured reporting system. (5)conducting clinical trials to ensure the accuracy of the output process.
Results：The project team was established on January 5, 2022, and successfully completed the implementation of structured reports in 32 departments by December 31, 2022. A total of 615 examination report codes and 341 report templates were established.
Conclusion：This project has made significant progress in the input of structured data. The successful use of structured reporting has enhanced the efficiency and information quality of the medical reporting platform, improved interdisciplinary communication, and opened up new possibilities for the future of medical reporting platforms, thus enhancing the efficiency and accuracy of medical information management. |
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