Introduction

The following documentation is the user stories prepared for the developer(s) to understand the perspective of prospective users as regards the radiology reporting framework.

Purpose:
To develop a guideline to support radiology reporting module in LibreHealth.
Intended Audience:
Application Developer(s)
Project Scope:
The scope of this document describes what will be provided for during the development of the radiology module to support radiology reporting for LibreHealth.
Items Covered
Radiology Reporting
Definitions:
The following are the definition of the key concepts used in the user stories developed below.

:Report - This is is the documentation developed by the user after thorough examination of the current study and comparison with other studies conducted on the patient.

Dictation - This is the process of documentation using alternative method to keyboard by using 3rd-party speech recognition software integrated with the Radiology Information System.

Draft - This is the stage at which a report or a study(images) assume when it has been claimed by a particular user. This would prevent other users from reclaiming it.

Addendum- This is additional reporting activity conducted on a report that has assumed a ‘Finalized’ status

Preliminary - This is is the stage at which a report assumes when awaiting approval from a user who is higher in ranks.

Finalized- This is the final stage of reporting. At this stage the report is visible to the ordering physician

Radiologist-A personnel trained to offer reporting support to the clinician

Staff- A full-fledge radiologist who is authorized to approve report to the ‘finalized’ stage

Trainee - A radiologist in training who conducts radiology reporting under the supervision of a staff

Instance-(To be added)

Study-This is a the folder containing the images sent by the Technologist.

Series- (To be added)

Use Cases

Components of the Radiology Information System

Template Generator The template generator serves as a repository for templates that can be reused by the user for reporting on different types of study. The sections will contain the following:

  • Indications: The main reason for the study

  • Date: This would be retrieved from the system when the particular template is chosen

  • Comparison: This would contain the previous study that the user wishes to compare the current study with

  • Technique: This shows the method used by the Technologist and the it would be retrieved from the study when the template is chosen

  • Findings: Would be recorded by the user throw dictation of typing

  • Impression: Would contain the speculations made by the user

Dictation Software:

This is the separate voice-recognition software that would be integrated with the reporting software for easy documentation. The use would speak to a compatible mouthpiece device to record reports. Apart from documentation, it would be designed to have additional functionalities such as command recognition and execution e.g. erase, remove three words forward, skip to 6 words backwards etc.

Reporting Software

This is an editor to be used by the user to perform reporting activities. Templates will be hosted on the Reporting Software and it will be resumed on claiming a new study or updating a previously claimed study.

  • User’s Report

  • The user’s report would be viewed on the reporting software and it will contain a breakdown of studies that are grouped under different categories based on the status of the study. The user’s report will update after every action is completed by the user.

  • The following categories may be used to group the studies that have been claimed by the user:

  • Approval Queue: This would contain the list of studies waiting to be approved by the user(Trainee) before the staff conducts final approval

  • Approved Today: The list of the studies that have been approved by the trainee on a daily basis

  • Touched today: This is the list of studies that have not been claimed but has been examined by the user.

  • Draft: This is the list of the studies that have been claimed by the user but the user has neither chosen any template nor started any reporting on it. This would also have the status of Draft in the main central user interface.

User Interface

This is the interface where major activity on the status of the study would be displayed. It would be enabled to retrieve the list of the ordered study and also have capability of sorting of studies based on different criteria e.g. priority, date, type of study etc.

  • Reading List: This is the list of studies sent by the Technologist

Image Viewer

This is an image viewing software used for the purpose of examining the batches of images in the study. It would be enabled with magnifying functionality.

Relationship Definition

Preconditions

  • The Interface would have been enabled to retrieve patient information from the EMR system

  • The dictation software would have been integrated with the reporting editor to enable the user to dictate observations.

  • The template generator would have been design to retrieve metadata information from the DICOM images in the report.

  • The image viewer would have been integrated to the user interface for image transfer

  • The reporting software would have been enabled to communicate directly with the reading list of the ordered tests and the dictation software

  • The RIS would have been designed to grant privileges based on roles of the user through recognition of login credentials (See login Procedure page)

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