Based primarily on teachings of Drs. Pierre Sasson and Alex Heffess, as well as the other radiologists at Mount Auburn:
Many doctors (and patients!) know radiologists only by their reports, and judge their quality based on the quality of their reports. Referring physicians lose confidence if are factual or typographical errors. Referring physicians often often only read impression. Imagine the patient reading report, and the report read being out loud in court.
Reports should be clear, concise, accurate, and precise. Brevity is often valued, although reports can be too long or too short. It is a balance between addressing all of the important points without extraneous words. Answer the clinical question and describe pertinent positive and negative findings; include relevant points to avoid phone calls.
Interventional procedural reports are different than typical diagnostic reports, often with a longer more detailed technique section. Mammography reports must use the specialized BIRADS terminology.
Not rule out
Need symptom, sign, or diagnosis
Key history to know:
Key for billing
Eg CT of abdomen and pelvis with intravenous contrast,mention angiogram, etc, post processing and 3d reconstructions
Sometimes combine studies if pertinent and same day
List pertinent studies you actually looked at, not every study the patient ever had
The findings section is an objective description of what is visible on the study images, including the pertinent positive and negative aspects. Many reports are moving towards a structured findings section (for instance, Liver: , Pancreas: , Spleen: ), although for some radiologists and in some instances a more conversational structure is used.
Always start the impression by answering the referring physician's question. Next order the important results by importance.
Interpretation, differential diagnosis, management
Don't just repeat findings, although sometimes brief reiteration of most pertinent findings useful in case where there is a differential
"should be considered"
Caution with word recommend, can box in referring physician
Use ACR appropriateness criteria
And other evidence based
Check that patient hasn't already had the exam
Can vary by who talking to - eg NP may need more guidance than specialized surgeon
Stay within realm of expertise - imaging or which sub specialty consultation
Can include citation - indication/increase quality of care, if referring MD wants to know can look it up
To our knowledge, the best managemnt at this time is
Discussed with, include date time
For unexpected finding or with immediate clinical relevance - protects you if they don't act on it
Record changes between significant changes from preliminary reports
Chatty versus structured versus personal narrative
Separate topics by paragraphs
Present tense for diagnostic studies
Past tense for procedures
Attend to details
Speech recognition can insert similar words - ascending descending, prosthetic prostatic, mm cm, degenerative degenerate, leave out 'no', hyper hypo, atypical
If you can leave a word out, do
Be clear and brief
Inconsistent serial measurements
Measure largest dimension, then 90 degrees
If disagree with prior re measure and describe
Check measure carefully, try stick with one type length either cm or mm
Avoid jargons, eponyms, abbreviations (unless common and universal such as AP/PA)
Caution with: is noted, identified, evidence of, visualized, demonstrates, exhibits, appreciated,
Extra caution for
clinical correlation. Buzz term gets clinicians upset, considered insulting, shifting responsibility. Instead be specific eg consider eval blood counts, focal tenderness at this site.
Cannot exclude - instead indicate suspected likelihood
Retrospectively - don't throw prior reader under bus, esp in mammo
Normal vs. unremarkable
Compatible, consistent with
Normal cxr vs. no acute cp da
Pet peeves to avoid
Infiltrate - opacity,
Progression, regression - see resist criteria
Stable vs unchanged
Cardiac silhouette - unless think pericardial effusion
Slow move to standard nomenclature, structured reporting
want to sound strong or lame?
Include links from JACR - don't use cannot exclude, etc
but also include what words TO use