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Tips to write a good radiological report Dr/Ahmed Bahnassy Consultant radiologist RMH •The ability to write clearly is a skill, not an art, and it is learned by practice... What is radi

Tips to write a good

radiological report

Dr/Ahmed Bahnassy

Consultant radiologist

RMH

•The ability to write clearly is a skill, not

an art, and it is learned by practice. Ferris M Hall1

What is radiological report

• The radiology report is the primary means of

communication between the radiologist and the referring physician The report reflects the

attitude, perception and capability of the

radiologist and serves as a legal document

• The process of reporting,

progressed from the

earliest handwritten

reports to today's

sophisticated speech

recognition systems

• Yet the form and content

of the radiologic report

itself have not evolved

along with the

technology that

facilitates its delivery to

the clinician

THE FIRST RADIOLOGY

REPORTS

• Dear Dr Stieglitz: The X ray

shows plainly that there is no

stone of an appreciable size in

the kidney The hip bones are

shown & the lower ribs and

lumbar vertebrae, but no

calculus The region of the

kidneys is uniformly penetrated

by the X ray & there is no sign

of an interception by any

foreign body I only got the

negative today and could not

therefore report earlier I will

have a print made tomorrow

The picture is not so strong as I

would like, but it is strong

enough to differentiate the

parts."

Hospital based reports.

• x-rays were welcomed as a

beneficial new technology

Specialist physicians and

surgeons who were shown a

"penetrating photograph" of

their patients believed they

needed no one else to

interpret the meaning of those

images

• At Boston Hospital in 1901,

x-ray pioneer Francis Williams

described the "standardized"

x-ray reporting and medical

record process:

• In the 1910s,

several private

practitioners took full service reports

to innovative and complex lengths

The report body

• Most radiologists use the format:

Discussion:

Impression

This is logical and follows the inductive method The

facts are weighed and a conclusion made In the modern hospital environment it has disadvantages Those

listening to the report have to wait until the end to hear the conclusion The same problem is inherent in reading reports online, the referring clinician may have to scroll,

to the conclusion.

The “C” factor

• The attributes of a good radiology report have

been summarized as the Six Cs Reports should

be :

• clear, correct, concise, complete, consistent,

and have a high confidence level

Be brief

• Clinicians have been asked what they want:

"brief description of the radiographic findings."

Most important finding first.

• Normal except for cancer RLL is unacceptable

• The physician may stop at normal.

Quantitate Quantitate Quantitate

• Measure if possible or use qualifiers- mild,

moderate, severe

Compare, Compare,

• Lack of comparison is a common factor in

physicians perplexity

Call Results

• for unexpected, life-threatening problems

Document the call in the report

Make the referring physician look

Be concise

• Eliminate unneeded or redundant words "There

is an area of linear atelectasis in the right lower lobe" should be - "Linear atelectasis right lower lobe."

Don’t be poisonous

• Unfortunately it is not uncommon to find a new

malignancy on a mammogram or chest

radiograph which in retrospect was present and reported out by a colleague as "normal"

Words or phrases to avoid:

Asking for Further Studies

• the more specialized the physician the less

appreciated are recommendations

• however, we cannot avoid responsibility to patient

• if further imaging necessary, document why ("CT may

be helpful in staging or localization or

characterization")

• if biopsy necessary: don't state that tissue is needed,

rather recommend appropriate method to obtain tissue ("mass whould be amenable to bronchoscopic biopsy

or percutaneous needle aspiration or endoscopy")

Mark (to a limit )

One of the most effective but least appreciated tools is marking

• Mark the end of all the lines and catheters Mark

the carina Mark the edge of the pneumothorax Outline collapsed lobes and anything else which you feel important

• Why?

• marks help convey what's important

Be strong in serious findings

• Possibility of malignancy.

• Life threatening infections.

• Specific etiology (TB)

Don't be vague

uncertain not definite in meaning, not explicit or precise, of indistinct ideas absence of clear

perception or understanding meaningless

• Be a journalist and not a reporter.

• Interpret

• Put yourself in the referring physician's

shoes .What would you conclude if you read this report?

Radiologists between clarity and

fear of failure

• Three quarters of a century ago, Enfield

criticized radiologists who issued written

radiology reports that:

• describe in detail all that the roentgenologist

sees in the film or on the screen but does not tell what he thinks about it, what conclusions he

draws from it, and what it means to him

• This kind of report "commits the roentgenologist

to nothing except accurate vision and good

description It tells much, yet almost nothing,"

• Enfield exhorted radiologists to "give not only

their opinion but also their method of arriving at that opinion."

• "it is the obligation of the radiologist to state what has been found as clearly and pointedly as

possible."

• Clarity and meaningfulness were the most

valued qualities of radiology reports among 200 referring physicians, according to a Canadian survey

Eyes and minds

• Radiologists should heed the words of

Rothman , who wrote that because radiologists are paid for using both their eyes and their

both sets of evaluations

• The body of the report should contain a

complete description of all abnormalities—that

is, everything that is seen with the eyes—

• but the conclusion should discuss only those

findings that are important to the brain

Don’t through the ball away from

you

• Radiologists should minimize, the use of such

phrases as "if clinically indicated " when

assessing abnormal radiographic findings

• Because radiologists are acknowledged to

possess radiologic expertise they should not

relinquish to nonradiology physicians the

responsibility of evaluating the significance of a radiographic finding that is unexpected or

unusual

Conquer your hesitation

• Radiologists should be mindful of the

following aphorism coined by one

radiology educator:

• "Do not let the fear of being wrong rob

LF, personal communication)

Lastly… Characters of good report

are the followings

• 6 “C”s clear, correct, concise, complete,

consistent, and confident

• it grabs the attention,

• conveys a message,

• and elicits a response