Radiology Reporting

Structure of a Radiology Report

History

Most important piece of information you can provide the radiologist

    • Increases our specificity and sensitivity

    • More tailored and relevant reports​

For pain:​

  • Location, location, location! ​

  • Acute vs chronic​

  • Your differential (e.g. suspect appendicitis or diverticulitis or obstructing renal stone)​


For oncology​:

  • Pathology (even subtypes of cancer look different!)​

  • Treatment history (surgery, radiation, chemotherapy, etc.)

Comparison

Often the most important tool at radiologists' disposal

  • If your patient has outside imaging, please upload for us to compare!

Certain pathologies (e.g. fractures) can appear age indeterminate

  • Radiologist may have to hedge and recommend "clinical correlation"


Growth Rate guides etiology

  • Lung consolidation developing in 1 month = likely pneumonia

  • Lung consolidation developing over years = likely malignancy

  • Long term stability often implies benignity

Technique

  • Includes information such as use of contrast, body parts scanned, and what timing

  • The way the study is performed (protocol) should be tailored to the clinical question

  • If ever unsure which study to order, provide comments for radiology to help protocol, or fee l free to call us!

  • Another useful resource is the ACR appropriateness criteria

  • Take a few minutes to explore the site (hyperlink above). What would you order in a complicated patient with acute pyelonephritis?


Findings

  • Typically the largest section, comprising the description of all relevant findings

  • Up to radiologists' discretion what to include as clinically relevant. Some findings may be deemed "unremarkable" such as:

    • Ovarian cystic lesions compatible with physiologic follicles

    • Scattered minimal osseous degenerative changes

Tips for your report

  • On noncontrast CT, findings are described as hypodense, isodense, or hyperdense

  • On postcontrast CT, findings are described as hypoenhancing, isoenhancing, or hyperenhancing, relative to background organ/parenchyma


Impression

Priority is to answer the clinical question!

  • "No acute pathology of the abdomen or pelvis" (for acute abdomen/pain)

  • "No suspicious mass of the abdomen or pelvis" (for weight loss/malignancy evaluation)

Includes additional summary of clinically relevant findings

Should not be just a repeated list of findings

  • e.g. "colonic diverticulosis without diverticulitis" should not be included unless a pertinent negative

  • e.g. "stable pulmonary nodule" does not give the reader information as to if this is a stable benign nodule, stable metastasis, or is indeterminate


Example Findings and Impression

History: "RLQ pain"

FINDINGS:

Bowel: Dilated appendix with signs of inflammation including wall thickening, hyperenhancement, and surrounding fat stranding. No associated fluid collections or free air.

IMPRESSION:

Acute uncomplicated appendicitis.