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While catching up with my Radiology reading on the net, I came across an interesting feature article by Dr. John R. Wilcox, M.D., titled ‘The Written Radiology Report‘ in the July edition of Applied Radiology Online.(Registration required - free and relatively easy for Radiology professionals).

The purpose of the article is to

help radiologists improve the quality of their written radiology reports by reviewing the components of a report, addressing grammar and writing style, and considering appropriate standardization.

I found it to be an extremely well-written article which should be required reading for all radiologists.

I especially liked three things in the article. The first is this statement:

Part of the problem with radiology reports arises because we do not really understand how important this document has become to the nonradiologist caregiver. This lapse is more understandable when you realize that most major radiology textbooks do not address the subject of report composition. This would be equivalent to a journalism textbook without a chapter on how to write an article. But journalism and radiology have a lot in common. Both professions require spending a great deal of time gathering “facts” and “data” and then reporting that material in written form for a reader.

the second is the author’s advice on report formats:

The key to a clear and concise radiology report that will provide reliable high quality communication is a coherent format. The radiology report is a diagnostic test result that should stand independent of the individual interpreting radiologist. The quality of the report should not vary as a result of there being different interpreting radiologists. This is a key principle in statistical quality control. The control of variation reduces liability risk because it ensures that important issues are addressed systematically. Using a standard format will significantly improve the ability of the report to communicate effectively. Variations in the report format create confusion for the reader, whereas a consistent location for the results, discussion, and conclusions assists the reader in understanding the report and its clinical implications. The scientific report format is a practical choice for the radiology report. This format is used by major scientific journals, is familiar to most physicians, and follows the general outline recommended by the American College of Radiology (ACR). It also supports the notion that the radiologic study is a “scientific test.” Table 2 presents a side-byside comparison of the scientific report format and a corresponding radiology report format.

and finally his grammar and structure guidelines:

1. Keep the intended reader in mind. Consider whether or not the reader understands what you are describing. Avoid the use of obscure terms understood only by radiologists.
2. Use active voice. For example, “I recommend” or “Recommend follow-up” instead of “Follow-up is recommended.”
3. Use verb tenses effectively. Use the present tense to describe the findings in a study that is before you at the time of dictation and use past tense for things that were seen during fluoroscopy or during a procedure.
4. Remember paragraphing. Separate different topics or ideas in your discussion by paragraph. This will make it easier for the reader to find the explanation of your impressions.
5. Organize an orderly discussion. Order the discussion logically, if possible. This can be done by anatomic location or ranked importance of findings.
6. Use complete sentences. Use complete sentences in the body of the report, but avoid long run-on sentences.
7. Avoid report inversion. The “Impression” section should not be longer than the body of the report.
8. Number your conclusions. Number the conclusions in the “Impression” section. This helps the reader understand how you rank the importance of your conclusions. Try to use either nominative phrases or single sentences.

What a great difference it would have made if I had been taught this as a resident!

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