how to write a decent radiological report

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.

History

• 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, 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 good

• A common phrase "fracture is poorly aligned" should be avoided.

• Extensive amount of post operative pneumoperitoneum.

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:

• missed • overlooked • not appreciated • should have been identified

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 )

• The pen is mightier than the swordOne 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.

• Vague: Wandering, roaming, unsettled, 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 brains, a complete radiology report must include 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 you of the joy of being right" (Rogers 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