How To Document A Good Radiology Report

Accurate radiology reports clearly communicate chronic incidental findings, the diagnosis or differential diagnosis, the clinical implications of radiologic findings, and any chronic findings that need additional workup or surgical intervention, along with recommendations for management. Error-free radiology reports contribute to patient care. With increasing workload, backlogs and malpractice risks posed by reporting errors, radiology transcription services are a viable option to generate accurate radiology reports. Outsourcing medical transcription will ensure seamless, accurate and timely capture of dictated radiology reports, including entry of patient information in the radiology information system (RIS). Transcriptionists also review and edit transcribed reports generated by speech recognition apps. However, radiologists need to know what constitutes a good radiology report. In this blog, we put together expert views on this matter.

The radiology report is an important document that helps guide patient care and becomes part of the patient’s permanent clinical record. These reports are seen not only by the ordering physician and but also by subspecialty providers involved in the patient’s care, other radiologists, and patients and their families. However, studies indicate that radiology reports are prone to different types of errors:

• Typographical errors
• Serious omissions such as missing tumors and lesions
• Misinterpretations – faulty reasoning, bias, and errors in interpretation can lead to an incorrect diagnosis
• Inconsistencies in report formatting and language

Creating a good radiology report that clearly communicates the findings of imaging tests is a complex skill that requires continuing effort and attention.

What is a Good Radiology Report?

A concise, well-crafted and well-organized digital radiology report would include the following information:

• Patient demographics – patient name, number, date of exam, type of exam
• Indication for study (such as a symptom or sign) or clinical history
• Technique used – study type and modality
• Description of pertinent findings – both positive and negative findings
• Radiographic diagnosis – a likely diagnosis or differential diagnosis that linked to clinical indication given for the exam
• Next steps
• Timed and dated electronic signature

An article published in RadioGraphics lists the 5 basic principles of clear, concise radiology reporting that can benefit both trainees and practicing radiologists:

• Provide the favored diagnosis or differential diagnosis along with the key finding to support it.
• State the findings clearly in understandable language. Avoid technical language that only radiologists know.
• Avoid clinically insignificant information and provide only information that is relevant to the ordering physician.
• Provide relevant detailed recommendations that can help the provider reach a specific diagnosis or will guide management of the condition.
• Continually work on improving the report based on provider feedback and following up biopsy results, hospital courses and procedural and operative notes.

Other tips from www.brighamandwomens.org:

• Highlight short, informative, and factual observations in the finding sections; avoid improper interpretation, overusing terms of perception, and redundancy
• Write complete sentences and don’t use abbreviations whenever possible
• Ideally, findings should be distinct and separate from the impressions.
• Ensure that observations are kept brief and succinct

Experts also emphasize that patients’ understanding should always be taken into consideration when documenting radiology reports.

Unstructured Reporting vs Structured Reporting

There are two types of radiology report formats – unstructured and structured – and each comes with its pros and cons. Unstructured reports or the standard free-text approach and are created by radiology transcription companies from the radiologist’s dictation. The narrated version allows the radiologist to describe relevant radiologic findings and offer several benefits such as conciseness and customization. However, it has certain drawbacks. As it focuses on including only specific information, important radiologic findings may be understated. Further, inconsistency in the language and format can cause miscommunication, making these reports challenging for both patients and other users.

Several studies show that, due to all these reasons, most referring physicians prefer structured radiology reports to free text (www.ajronline.org). In this type of report, structured templates allow for reporting the findings with brief observations, while maintaining the meaning of the findings with actionable information. Proponents say it improves readability, reduces risk of omission of relevant information, and presents the critical findings effectively. Medical transcription companies with expertise in radiology documentation can ensure as much relevant information as possible, easing the work overload of the radiologist.

Medical imaging reports should be optimized to provide pertinent information to physicians reading them as well as patients. The benefits of well-crafted, optimized radiology reports also include proper communication among specialist care teams, and improved algorithm training, according to Quantib, a market leader in artificial intelligence in healthcare & radiology.