Amidst all the discoveries and rapid progress in the field of Radiology, it is our responsibility to be able to deliver concise reports of all that we see. Our reports being considered our signature and sometimes our” first and last impression”.During post-graduation, one starts to be exposed to different styles of drafting reports and often we are confused as to which ones to adopt.So much so, we spend our time divided equally between image interpretation and working on a console with formatting and punctuation.
In the modern era, the direct communication between a radiologist and physician has substantially decreased, hence formal written reports must be ”structured” and deliver the right information.“Our reports should not only be thorough but also direct, clear, and concise so that the referring physician understands the information and patient care is optimized,” according to Dr. Pamela Johnson, Associate professor of radiology residency program director at Johns Hopkins Medicine in Baltimore.
We must answer four questions- four questions: what do I see on the images, what do I think the findings mean, what do I want the referring physician to conclude from my report, and what do I think the referring physician should do next. Positive feedback from other specializations must be appreciated. Distinct findings and impression sections exist so that the impression represents the interpretation of the findings rather than the simple reiteration of the same.
There are split views on the choice of words as no uniform reporting system is followed and no strict guidelines.An article Banned: Top 8 words or phrases to avoid in radiology reports By Philip Ward, AuntMinnieEurope.com in 2013 specified use of words like ‘‘can not rule out”, ”suspicious” and ” needs clinical correlation” as inappropriate.However similar words( suspicious/probable) continue to be used under BIRADS for breast pathology characterization. What about situations where all investigations are not provided by the patient but the report delivery is pressurized. After all, the Teleradiologist sometimes has access to only images and not the patient.
Due to the high risk of medico-legal issues and PC-PNDT act, careful choice of words is required.Penning down anatomical variations, for example, can be important as a surgery may be planned years down the line.Somebody else picking up the same finding can sadly lead to ridicule in our competitive work culture.
Clinical Radiology Written Report Guidelines by The Royal Australian and New Zealand College of Radiologists published this year is a good example.Standard templates and guidelines may be the need to our diverse medical setup.
We must not embarrass our field by hiding under the cover of not having a direct response to the patient’s treatment as a radiological documentation is now essential for most medico-surgical planning.It is thus our duty to take a brief history and prior surgical/intervention reports for comparison.With the trends now shifting to orthopedicians and neurosurgeons not requiring a radiologist’s interpretation, we might need to include finer details like precise measurements with respect to standard landmarks and residual deformities, referring to patient-specific needs.It is the need of the hour to save our profession and preserve its glory.Let the radiologist not depend on others but we ourselves form the central, essential pivot of all medical fields.
Source: Mohan C. Subtle versus the obvious – “Is it time for the Smart Radiologist?”. Indian J Radiol Imaging [serial online] 2017 [cited 2017 Oct 26];27:117-8
Dr. Niharika Prasad,
The author is MD (Radiodiagnosis) and is Senior Resident, Dept of Radiology in All India Institute of Medical Sciences, AIIMS Patna. She is a member Editorial Board, Radiology at Specialty Medical Dialogues.