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:
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