On Radiology Reports: Guidelines for Dictations


Part I: Guidelines for Dictations

The Role of the Radiology Report: The Radiologist as Consultant

Our reports are our product. The report, based on the patient’s exam, presents the findings of the radiologist and expresses their clinical judgment or diagnosis. Performing an examination assumes certain responsibilities, regardless of how simple the exam may be, and the report should reflect that these commitments have been respected. This chapter defines the role of the radiologist as a physician—not as a technician, not as a picture taker—but as an independent decision-maker involved in patient care and management at the same level as other clinicians.

Structure of the Radiology Report

Very early in the development of radiology as a specialty, attempts were made to standardize reports in order to communicate the radiologist’s findings with the clinician. The fact that no standard report has been adopted proves that no format has been found or accepted. Only the BIRADS classification for mammography has attained any sort of standard for reporting. This chapter focuses on the essential elements of a report—the history, technique, a description of the findings, and the impression—and outlines what information goes where in the report. It concludes by addressing the growing development of structured reports.

Reporting Style

Style is the writer: it is a personal expression of what the radiologist knows, their former training, their referring physician’s preferences, and even one’s past mistakes. A uniform style is desirable, because it would eliminate discrepancies in terminology such as “normal bowel gas pattern” versus “nonspecific bowel gas pattern.” This chapter focuses on the three essential elements of reporting style: clarity, brevity, and pertinence. It also addresses the impediments to attaining clearly written reports.

Medicolegal Aspects of the Radiology Report

Radiologists are held to the standards set by the American College of Radiology. Although the goal of these guidelines is to promote quality patient care, they frequently find a role in litigation as well. This chapter familiarizes radiologists with these guidelines and shows ways to adhere to the guidelines in terms of risk management. Emphasis is placed on communicating with referring physicians as well as some of the more subtle medicolegal points such as signing another colleague’s report.

Billing Aspects of the Radiology Report

“If not reported, it was not done.” This simple dictum drives the coding and billing of radiology reports. Common omissions in reports impact billing. If a “complete” abdominal ultrasound, for example, does not mention the inferior vena cava or aorta, it becomes a “limited” abdominal ultrasound—and the reimbursement will reflect the difference. This chapter addresses the key elements required in the report to capture all the codes for reimbursement for all modalities, including radiography, CT, MRI, Ultrasound, Nuclear Medicine, and basic interventional radiology. Also addressed are post-processing code requirements for more elaborate exams such as 3D CTAs and CT urograms.

Words and Expressions Commonly Misused in Reports

Modeled after the classic chapter in Strunk and White’s Elements of Style, this chapter lists common errors in wording of radiology reports. For example, the term “the common duct” is ambiguous: there are two ducts in the biliary system, the common bile duct and the common hepatic duct, and the correct term should be specified. The section also addresses words that sound alike (“continuous” and “contiguous”) but have different meanings. Finally, common pitfalls such as verbosity and jargon are exposed for what they are: impediments to clarity of the report.

Ethical Dimensions of Radiology Reports

The radiology report is the medical document that qualifies the radiologist as a physician and as a specialist. Through the report, the radiologist exerts influence on patient care, and by so doing, the radiologist becomes responsible. Certain responsibilities are inherent to the radiologist’s report: communicating clearly, impacting patient care, avoiding needless expenses, and respecting the patient as well as the referring provider.

Potential Pitfalls in Reporting

This chapter outlines some of the more common errors made in reports, with the intent of highlighting the pitfalls so that radiologists may avoid them. Some of the pitfalls you may find surprising, as they occur with some of the most simple and straightforward exams we do, such as the preoperative chest radiographs. Others are more obscure or simply a matter of semantics, but the potential repercussions which may ensue are well worth making the effort to avoid.


Part II: Sample Dictations

Part II of the text provides readers with sample reports from all areas of radiology: neuroradiology, chest, vascular and interventional radiology, nuclear medicine, pediatric imaging, cardiac imaging, obstetrics, gastrointestinal and genitourinary imaging, mammography, and musculoskeletal imaging.

These samples are in no way intended as absolutes, but rather are offered as guidelines for radiologists in training and in practice to see what elements need to be included in a complete report.

Below is a sample entry for the placement of an IVC filter:


</CLINICAL HISTORY/>
@@
</TECHNICAL PROCEDURE/>

Informed consent was obtained prior to the procedure. The
procedure was performed under sterile conditions and local
anesthesia. @@ (Add Conscious Sedation Macro if
requested-delete this sentence and jump code if not requested).

Ultrasound of the @@ @@ was performed for evaluation of venous
patency. The ultrasound examination demonstrated patency of the
@@ vein. Hard copy documentation of the ultrasound images was
recorded and made a permanent part of the patient’s record.

Needle puncture of the @@ vein was performed using direct
ultrasound guidance. Following venous access a guide wire was
advanced into the inferior vena cava using fluoroscopic guidance. A
filter introducer sheath was then placed into appropriate position in
the IVC. Contrast was injected and a standard inferior vena
cavagram was obtained. An appropriate deployment site for the filter
was chosen based on the IVC images.

A @@ retrievable IVC filter was then deployed in the infra-renal IVC.
Contrast injection was performed to document the position and
orientation of the filter. Hard copy documentation of the fluoroscopic
images was recorded. The introducer sheath was then removed and
hemostasis was achieved with manual compression. The venous
entry site will be closely observed for a short period of time following
the procedure. There were no procedural complications.

</RADIOGRAPHIC FINDINGS/>
The inferior vena cava is normal in caliber and patent. No
intra-luminal thrombus is identified. Single renal vein inflow is
identified in normal position bilaterally. Final images show
satisfactory position and orientation of the filter in the infra-renal IVC.
</IMPRESSION/>
Successful IVC filter placement.


Appendices:

ACR Practice Guideline for Communication of Diagnostic Imaging Findings

Robert Sherman, The Roentgenologist as a Consultant (classic essay
on reporting)