Components of a Report

Demographics

OBJECTIVES:

To ensure the report describes the correct image(s) of the correct patient
By matching patient demographics in request to demographics on images.
By ensuring that the image being interpreted is the correct type of study and has the correct date, time, and access/study identification number.
By comparing the appearance of the patient to prior, if possible, to ensure it is the same person.
To inspect image annotations and ensure they are correct.
To explore steps to take in correction of a mismatch or incorrect image.

NOTES:

AUTHOR: Linda Lanier MD

ACKNOWLEGMENTS:

COMMENTS:

REFERENCES:

Indication for Study

OBJECTIVES:

To understand appropriate reasons for the study and document them in the report
To attempt to identify the reason for study if not given
To document if no reason can be identified
To issue an addendum if history/reason becomes available that alters the interpretation

NOTES:

AUTHOR: Linda Lanier MD

ACKNOWLEGMENTS:

COMMENTS:

REFERENCES:

Stolberg, Harald Radiology Reporting Handbook
Paris, Allan Jr, Handbook of Radiologic Dictation
Canadian Prof Devel, Rad Reporting (McMaster)
ACR Guideline for Communication

Technical Procedural

OBJECTIVES:

To communicate the technique of the study performed
To document contrast or medications administered
To document any deviation from the routine procedure
To document any limitations of the study

NOTES:

AUTHOR: Linda Lanier MD

ACKNOWLEGMENTS:

COMMENTS:

REFERENCES:

e-Medicine Cholecystitis and Biliary Colic, Sally Santen, MD
http://www.emedicine.com/EMERG/topic98.htm
e-Medicine Hypertrophic Pyloric Stenosis Janet R Reid, MD
http://www.emedicine.com/radio/topic358.htm

Comparison/Supplementary

OBJECTIVES:

To recognize the need to make comparison to prior studies
To document appropriate comparison studies used
To learn to use supplementary data, if available, and to document its source
To attempt to explain or resolve discrepancies in results if they exist

NOTES:

AUTHOR: Linda Lanier MD

ACKNOWLEGMENTS:

COMMENTS:

REFERENCES:

Body

OBJECTIVES:

To describe relevant findings in a clear and concise manner
To organize thoughts and report in a way that emphasizes the more important findings first
To construct complex reports using methods such as grouping comments and separate paragraphs to increase clarity
To articulate clearly what the image findings MEAN and communicate the significance of the findings

NOTES:

AUTHOR: Linda Lanier MD

ACKNOWLEGMENTS:

COMMENTS:

REFERENCES:

Summary/Impression

OBJECTIVES:

To concisely summarize findings toward a diagnosis or differential diagnosis if a diagnosis isn’t possible
To list the most important findings first
To answer the question asked
To offer suggestions if further evaluation is indicated
To mention any untoward reactions to medicines or contrast administered

NOTES:

AUTHOR: Linda Lanier MD

ACKNOWLEGMENTS:

COMMENTS:

REFERENCES:

Components of a Report

Demographics

Indication for Study

Technical Procedural

Comparison/Supplementary

Body

Summary/Impression

Curriculum in Radiology Reporting