Reporting

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Author: Mikael Häggström [notes 1]

Following are general notes on reporting on radiology images. For guidelines on writing reporting guidelines in Radlines, see Radlines:Editorial guidelines.

Depth

Factors supporting a relatively more comprehensive report:

  • Double-reading: If your report is likely to undergo double reading, it needs to be more detailed, particularly in the inclusion of conditions you have negated, because the doctor who will do the double reading then gets to know that you have looked at those locations.
  • Lack of previous reports, whose minor findings can often be summarized similar to "otherwise no additional findings since previous exam on [date]".
  • Lack of explanation from existing evidence. In contrast, in for example an X-ray of the foot in a patient with foot pain, the finding of a fracture generally makes is unnecessary to report on for example very small calcaneal spurs.

Multiple instances of the same type of pathology (such as lung nodules or diseased joints) can often simply be reported as such, at least with a particular mention of the largest or the most severe example thereof, such as "at least moderate joint space narrowing and erosions of the DIP-joints, being severe at dig-III".

Comparison

A report should include the date(s) of any images used for comparison. Comparison (or mention thereof) is not needed if absence of pathology is clear even without it. For short reports, the date (in local date format) can be integrated in a sentence if the form layout allows, such as "Compared to the CT July 3, 2018, the consolidation...". Where comparisons are expected for multiple findings in an exam, the comparison should be mentioned separately at the beginning of the report, such as "Comparison: July 3, 2018", each item can be described similar to "compared to earlier...".

The clinical context for a previous exam should in some cases be mentioned in order to put relevance to similar findings. For example, radiodense fat around the gallbladder on both an old and a current CT is more likely a sign of cholecystitis if there were clinical symptoms of it on the previous occasion, suggesting two separate episodes.

Certainty

The same word used describing the certainty of findings can refer various probabilities, differing between radiologists as well as clinical situations. The following is a suggestion of words, in an attempt to sort them from most to least probable:

(is)
probably
likely
suggestive
suspicious
maybe
possibly
(non-lethal condition) cannot be excluded
not likely
(lethal condition) cannot be excluded
not


Suggestions to clinicians

Make suggestions about further imaging only if you know it is clinically relevant, which is usually not the case in for example incidental findings in patients with known cancer.[1]

Tailoring

The information contained in the reporting sections in Radlines assume that the clinician has requested the imaging for the topic of the article at hand, but should be tailored to any particular questions or requests by the clinician. Any relevant findings beyond the issues or questions raised by the clinician should also be mentioned. For automatically generated titles, you may need to correct or make a note of any difference to the projections at hand.

The most important findings can be moved to near the top of the report if feasible, but doctors performing subsequent double-reading may prefer a consistent anatomic order.

If a certain grammatical rule has a risk of making the report less clear to the reader, ignore it.

Restrict acronyms/abbreviations to those who are certainly well known among all doctors, such as "cm".[notes 2]

See also

Notes

  1. For a full list of contributors, see article history. Creators of images are attributed at the image description pages, seen by clicking on the images. See Radlines:Authorship for details.
  2. Acronyms/abbreviations increase reading speed only if the reader is familiar with the abbreviated terms:
    - Narod, S.A.; Ahmed, H.; Akbari, M.R. (2016). "Countercurrents: Do acronyms belong in the medical literature? ". Current Oncology 23 (5): 295. doi:10.3747/co.23.3122. ISSN 1718-7729. 

References

  1. Ginsberg, Lawrence E. (2010). "“If Clinically Indicated:” Is It? ". Radiology 254 (2): 324–325. doi:10.1148/radiol.09091736. ISSN 0033-8419.