Structured radiology reporting

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Category: Education
     
 

Presentation Description

Review of some articles on how we can introduce a structure into our reporting that facilitates good clinician communication and keeps us medicolegally safe

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Presentation Transcript

Structured Radiology reporting:

Structured Radiology reporting The ability to write is clearly a skill, not an art, and it is learned by practice . Dr. Varun Babu MD Al-Sabah Hospital Kuwait

Why is it important?:

Why is it important? Dr. VB

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Dr. VB

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Dr. VB Demographics

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Title of study Technique of study Dr. VB Demographics

Title of study:

Title of study Dr. VB CT Abdomen Plain KUB Triphasic liver CT CT urogram CT abdominal angiogram CT Chest HRCT chest CT pulmonary angiogram Combined CT Brain and paranasal sinuses MRI pelvis with abdomen screening MRI Brain with cervical spine screening Demographics

Technique of study:

Technique of study Dr. VB CT Routes and type of contrast administered Phases acquired Special views/positioning MRI Sequences acquired Phases done Region specific sequences Demographics

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Keep it short Notation of symptoms important for reimbursement Do not repeat age and sex Dr. VB History

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If pertinent history is not provided – state specifically Medicolegal Subtle message to ordering physician Conveys diagnostic uncertainty Dr. VB History

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Compare images and not reports. List date of study and if from outside our hospital – PACS ID. Preferably use ‘In comparison to’ or ‘as compared to’ towards the end of the report. Dr. VB Comparison

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Dr. VB Findings

Brevity:

Brevity Avoid beginning sentences with ‘There is..’ ‘There are..’ Avoid redundant words and phrases Review of the scan in bone window shows no metastatic disease. No bone metastases. Dr. VB Findings

Brevity:

Brevity Use ‘unremarkable’ or ‘normal’ instead of long winding phrases that convey less meaning. Narrative vs concise sentences Dr. VB Findings

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Words that do not serve any useful function should be avoided Dr. VB

Brevity:

Brevity Acronyms GB/ UB Present tense Dr. VB Findings

Clarity:

Clarity ‘Evidence of’ Portal hypertension Pleural effusion ‘significant’ lymphadenopathy Dr. VB Findings

Clarity:

Clarity ‘cannot be excluded’ Double negative ‘non specfic bowel gas pattern’ Dr. VB Findings

Clarity:

Clarity Mentally visualize critical findings Size of a lymph node Non quantifiable data Pleural effusion Ascites Dr. VB Findings

Pertinence:

Pertinence Relevant negatives Jaundice Relevant vs incidental findings Dr. VB Findings

Pertinence:

Pertinence Non specific or equivocal findings Advice next investigation >4 differentials – NOT helpful ‘if clinically indicated’ ‘clinical correlation is suggested’ Dr. VB Findings

Pertinence:

Pertinence ‘was not seen on the prior study’ Increased/decreased in size or Unchanged since prior study ‘too small to characterize’ Comparison Stability/progression Dr. VB Findings

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Always address the clinical question Concise and precise In order of importance of findings Avoid descriptions which don ’ t lead to a conclusion Dr. VB Impression

References:

References Style guidelines for radiology reporting. Coakley et al AJR:180 Feb 2003 Language of the radiology report: Primer for residents and wayward radiologists AJR:175 Nov 2000 Dr. VB

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for your patient listening. Dr. VB

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