Radiology reports are arguably the most important products radiologists contribute to patient care. Many, however, receive little education on the topic during training and are forced to pick it up on the job or by reading other imaging reports.
A team of four radiologists representing institutions in the United States, England and Australia recently detailed principles that rads—young and old—can adopt to enhance their reporting. A key part of doing this, they explained, is making these documents more accessible to others.
“The audience of the radiology report extends far beyond the ordering provider and includes patients and their families, medical support staff, subspecialty providers, other radiologists, and research interests,” Michael P. Hartung, MD, with the University of Wisconsin-Madison School of Medicine and Public Health, and colleagues wrote Oct. 1. “Creating a report that fulfills the needs of this diverse group is a formidable if not quixotic ambition.”
The authors outlined foundations of clear and concise reporting, focusing on the findings and impression sections. Below are key takeaways from their article, published in RadioGraphics:
Improving the findings section
- Rads should save interpretations for the impression section and use findings to emphasize facts. One exception, the group noted, is for “buried findings,” which are incidental, benign or clinically insignificant. When including such info, it must be clearly labeled, they explained.
- Perception terms, such as “is seen” or “is present” add no meaning to reports and should be avoided, when possible. This is particularly important in structured reporting.
- Limiting redundancy can help ordering physicians comprehend and increase engagement with reports. This skill typically comes as rads gain more experience, Hartung et al. wrote.
- Organizing findings can bolster the clarity of reports and should be top of mind. Many practices have turned to structured reporting and templates to achieve this, but rads may also consider numbered lists.
Improving the impression section
- It will be difficult to create a report that suits every audience, but imagining yourself as the reader can help. If an ordering provider can understand the document, they can easily translate that information to patients.
- Begin this section by including the favored diagnosis, the authors noted. Oftentimes rads may quickly jump into detailed findings and overwhelm the reader.
- The impression section should omit unneeded technical language and avoid information irrelevant to the diagnosis.
"The impression should not require an internet search to be understood by the ordering provider,” the authors wrote.
- It’s difficult to get this section right on the first try, Hartung and colleagues wrote. Rads shouldn’t be afraid to go back and revise the impression section in order to offer their clearest recommendations.
“The radiology report represents the distillation of a decade or more of medical training,” the authors concluded. “Reporting is a continual work in progress that matures throughout a career with experience, confidence and follow-up.”
Read more tips and details from the authors on improving your radiology reporting here.