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Breast Imaging

E2652. The Five Key Elements of a Clinical History: Does Training Technologists Improve Quality?

Severs F,  Sam K,  Fuqua B,  Ortiz-Perez T,  Ebuoma L. Baylor College of Medicine, Houston, TX

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Background Information: In breast imaging, a clinical history (CH) is provided by the technologist along with the breast images. The CH details the reason for imaging as well as pertinent prior history and family history. A comprehensive CH aids the breast imager in properly interpreting the presented images. A noncomprehensive CH results in reduced efficiency due to the need for additional time spent interviewing the patient or browsing through the patient’s medical record. Additionally, a thorough CH may also provide the radiologist with insight that can enhance image interpretations and potentially change treatment and follow-up recommendations (i.e. screening MRI, genetic counseling, etc.). Five key elements were identified for a comprehensive CH: patient age, sex, family history of breast cancer, significant personal breast history, and current complaint or reason for imaging. A systematic approach to developing the CH was derived to ensure uniformity over all reports. A 10-minute training session on how to systematically construct a comprehensive CH addressing the five key elements was given to the breast imaging technologists at our institution. The CHs prior to and after the training session were evaluated for compliance and completeness. The CH is part of the final report as the “reason for examination/clinical indication”.

Educational Goals/Teaching Points: The educational goal was to improve the completeness of CHs provided by breast imaging technologists. We surmised that a single short training event for the technologists would greatly improve the completeness of CHs.

Key Anatomic/Physiologic Issues and Imaging Findings/Techniques: We reviewed 701 reports of mammography and ultrasound examinations including 444 before and 257 after the CH training session. About 80% of records were mammography and 20% were ultrasound examinations. All five key elements of the CH were included significantly more in reports following training compared to before training (p < 0.0001 for each element). Before training, most reports did not include the CH key elements. After training, most reports contained patient age (before vs after: 1% vs 95%), sex (1% vs 94%), family history (6% vs 87%), personal breast history (36% vs 71%), and the current complaint or reason for imaging (63% vs 98%).

Conclusion: A single 10-minute training session for the technologists at our institution resulted in significantly more inclusion of the five key elements of a comprehensive CH. This aids the breast imager in interpreting the presented images and increases efficiency by reducing the need for additional interview time spent with the patients and time browsing through medical records. This also provides a comprehensive “reason for examination/clinical indication” on the final report.