The radiologic report: a realistic approach.
The radiologic report records all of the important steps taken in the practice of radiology and should be evaluated with special interest. The literature reflects the subjectivity inherent to a field left to personal interpretation, and few prospective studies of radiologic reporting are available. To determine the characteristics of the ideal radiologic report, the authors held workshops with two groups of radiologists and residents in radiology. The following items (in order of priority) were considered of prime importance by the participants and are discussed here: expression of an opinion and presentation of a workable differential diagnosis; an answer to the referring physician's question; a list of the limitations of the examination, if any; open-ended recommendations to the referring physician; integration of the findings with the clinical context; a synthesis of the findings obtained with various imaging modalities, when pertinent; and a complete description of the findings. The radiologic report has been compared to a scientific paper, and this comparison suggests the format for bringing these items together. The resulting realistic blueprint for the ideal radiologic report can be tailored to fit every imaging situation. Moreover, it can be a useful tool for evaluating the whole imaging process.
Department of Radiology, Centre hospitalier universitaire de Sherbrooke, Que.
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Blais
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Samson
D006801:Humans; D008499:Medical Records; D011871:Radiology