Published May 2000
Revised Feb 2005

Radiology Report
A picture is worth a 1000 words
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.

Style:

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, or worse, page to the conclusion.

A less popular format:
Diagnosis or Findings
Discussion.

This reverse logic brings the most important information to the top where it is seen or heard first. This is the format preferred by the referring clinician.

Which ever format is used a few caveats:

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 the loss of a malpractice lawsuit.

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. Describe the facts. Juries do not understand poorly

Don't be vague. Be a journalist and not a reporter. Interpret. Avoid "if clinically indicated." Don't hedge. Put yourself in the referring physician's shoes. What would you conclude if you read this report?
Key components of the report
  • description of technique
  • quality
  • limitations of the examination
  • description of radiologic findings
  • diagnostic impression
  • differential diagnosis
  • recommendations for further investigations
Words to avoid

inadvertent vs unintentional - legally, inadvertent means careless.
Brevity is the soul of wit

Lawyers will argue that reports should be wordy as a defense against malpractice. Short reports equate to haste and carelessness. However, long reports cost money to produce and read. Be succinct. Eliminate unneeded or redundant words. "There is an area of linear atelectasis in the right lower lobe" should be - "Linear atelectasis right lower lobe."

Redundancy is common. Example: lung fields. Redundant (and silly concept). "The lung fields are normal" becomes "normal lungs".
Eliminate "There is". There is a nodule in RUL" becomes "RUL nodule"
Missed cancer conundrum

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
  • error
  • mistake
  • overlooked
  • not appreciated
  • obviously present
  • should have been identified
Suggestion: "In retrospect, a vague opacity may have been present in this location."
Further Studies

Contentious, most physicians dislike being told what to do and feel that radiologists order too many follow-up studies

In general:
  • 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")

Kilroy was hereKilroy was here
The pen is mightier than the sword
One of the most effective but least appreciated tools is the grease pencil. Mark up the films. On portables, 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? Red marks help convey what's important. There's a more subtle message that is also relayed.

I've been there. I'm involved. I have an interest in patient care. Which brings up the story of kilroy.
Portable chest x-ray
The Legend

Kilroy is an American legend. The story began in World War II, where on faraway islands and European battlefields, his name greeted GI's. Wherever GI's kicked up dust or slogged through mud, Kilroy's trademark was there first, and he certainly reached some places even the toughest avoided. The impudent announcement that "Kilroy was here," decorated walls, pillboxes, and any other handy surface from Hitler's "Eagle Nest" at lofty Berchtesgaden to isolated beaches in the far Pacific.

Origin

When the war came in 1941, a shipyard inspector, James J Kilroy, wanted to make sure that his boss knew he was on the job. To show his superiors how efficient he was, he chalked his name on the rivets that were his responsibility. Soldiers on the troop ships took up this catchy signature - and the rest is history.

Many centers have gone to filmless radiography, with images transmitted to monitors for viewing. Such systems need a system to mark the films. Kilroy was here.
For more information, please refer to the
ACR Standard for Communication: Diagnostic Radiology
Curriculum in Radiology Reporting from the Uniiversity of Florida
  • Series of modules that provide instruction and guidelines for reporting and communication skills
References

Smith JP. Risk management for the radiologist. AJR 1987; 149:641-643.

Reports should not contain words that could be admission of negligence (mistake, inadvertent, oversight). Referring clinicians work should not be maligned (fracture poorly aligned).

Clinger NJ, Hunter TB, Hillman BJ. Radiology reporting: attitudes of referring physicians. Radiology 1988; 169:825-826.

Referring clinicians prefer summary statement at beginning. 50% thought reports didn't address clinical question

Berlin L. Reporting the "missed" radiologic diagnosis: medicolegal and ethical considerations. Radiology 1994; 192:183-187.

Unethical to withold reference to previous missed diagnosis. Report misdiagnosis, should be succint, matter-of-fact and nonjudgemental

McLoughlin RF, So CB, Gray RR, Brandt R. Radiology reports: how much descriptive detail is enough? AJR 1995; 165:803-806.

Referring clinicians prefer reports that include a brief description of findings

Berlin L. Communication of the urgent finding. AJR 1996; 166:513-515.

Any suggestion that finding important - CALL, keep trying until office or alternate physician assumes responsibility. If this fails call patient. Document call in report.

Sobel JL, Pearson ML, Gross K, et al. Information content and clarity of radiologists' reports for chest radiography. Acad Radiol 1996; 3:709-717.

Reports vary widely in terms used to describe abnormalites and vary in large degree as to certainity of what was found.

Berlin L. Radiology reports. AJR 1997; 169:943-946.

Less than 50% of referring clinicians read the full radiographic report. Groups should reach consensus on how to formulate their radiology reports.

Berlin L. Malpractice issues in radiology. Admitting mistakes. AJR 1999; 172:879-884.

Be honest with patients. Avoid emotionally charged language ("I screwed up"). Show compassion. Document coversations between patients and families. Contact hospital risk management.

Cascade PN, Berlin L. Malpractice issues in radiology. American College of Radiology Standard for Communication. AJR 1999; 173:1439-1442.

Communication errors fourth moste frequent allegation against radiologists. Risk management includes: documenting any technical limitations, comparing with prior films and documenting reasons if not done, suggest follow-up when appropriate, corrent and sign reports, verbally communicate urgent findings.

Berlin L. Comparing new radiographs with those obtained previously. AJR 1999; 172:3-6.

Standard of care is to compare. If old films cannot be obtained, state "previous radiographs are unavailable for comparison."

Berlin L. Malpractice issues in radiology. Alliterative errors. AJR 2000; 174:925-931.

Alliterative error: bias of previous reports clouding the judgement of the current interpretation, often the same (mis)interpretation propagated from report to report

Berlin L. Must new radiographs be compared with all previous radiographs, or only with the most recently obtained radiographs? AJR 2000; 174:611-615.

All attempts must be made to compare old films, reasons for not doing so should be documented in report. Also consider comparing to ALL radiographs, not just the most current

Berlin L. Communicating findings of radiologic examinations: whither goest the radiologist's duty? AJR 2002; 178:809-815.

Current trend is to communicate imaging findings directly to patient.

Naik SS, Hanbidge A, Wilson SR. Radiology reports: examining radiologist and clinician preferences regarding style and content. AJR 2001; 176:591-598.

Referring clinicians prefer itemized reports over prose reports.

Gunderman R, Ambrosius WT, Cohen M. Radiology reporting in an academic children's hospital: what referring physicians think. Pediatr Radiol 2000; 30:307-314.

Most important characteristic of radiology report: timeliness. Most important characteristic of content: answer question in indication.

Berlin L. Relying on the radiologist. AJR 2002; 179:43-6.

Referring clinicians heavily rely on radiologists opinion, courts use this reliance as major factor in apportioning liability

Berlin L. Are radiologists contracted by third parties to interpret radiographs liable for not communicating results directly to patients? AJR 2002; 178:27-33.

Interpreting radiographs for nonphysicians (example "B" readings). States differ as to whether patient-physician relationship established. Consult legal counsel. Ethical standards demand that procedures are in place to communicate results to patient or patient's physician.

Williamson KB, Steele JL, Gunderman RB, et al. Assessing radiology resident reporting skills. Radiology 2002; 225:719-22.

Reporting skills increase with increasing experience and can be measured.