Page 32 - Diagnostic Radiology - Interpreting the Risks Part One

SVMIC Diagnostic Radiology: Interpreting the Risks

Elements of a Well-written Radiology Report

An accurate, intelligent, concise, and detailed report that is
reliably delivered to the referring provider (and sometimes the

patient as well) as soon as possible is a laudable goal that is not
often achieved. Let’s look at some elements of a good radiology

report.

Comprehensive Format

A radiology report should include demographics, relevant
clinical information, clinical issues, comparison studies and

reports, procedures and materials, potential limitations, findings,
and overall impression.
14

Appropriate Content

Nonstandard abbreviations should be avoided to preclude
ambiguity. In most cases, significant misinterpretation by

referring physicians can be avoided by noting the contextual
implications of an abbreviation. However, it can be frustrating

for the referring physician to spend time trying to decipher
the meaning of a nonstandard abbreviation. Similarly, numeric

dating should be avoided to prevent errors related to an
alternate dating systems. For example, use “Aug. 8”, rather than

“8/8”.

The importance of making comparisons with old studies
cannot be overemphasized. However, some radiologists make

comparisons but neglect to mention them in their reports.
Mentioning comparison studies is critical. It is not sufficient

to merely compare; comparisons must be documented with
relevant references to prior studies throughout the report.

14 ACR Practice Guidelines for Communication of Diagnostic Imaging Findings, Introduction, (revised
2014).

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