[The radiological report: shaping it up].
The studies found in the literature investigated the structure of the radiological report, its standardization, communication with the general physician, regulations, and the medicolegal importance of the report. What to include in terms of content was most often considered: identification, clinical context and questions asked, technique and technical limitations, ordered results, relevant negative elements, a conclusion including a response to the question, diagnostic orientation, and suggestions for other examinations if necessary. In terms of the report's form, computerized reports have advanced the debate, opposing free composition and the structured report. No recommendations on the style were found in the recent studies, even though the problem is not a new one. In 1904, Hickey introduced the term "interpretation." In 1922, he observed that the style of reports was always individualistic and often eccentric. He suggested standardizing the reports to "avoid verbosity and encourage concision and clarity." After revising the information that should be included in a report, we wish to emphasize the form and style of the writing. This is not a scientific work, but rather we wish to express our opinion through a critical analysis based on examples taken from patient files. Many reports contain needlessly repeated words and language tics that harm the credibility of the analysis. The main qualities of the radiological report that are useful for the clinician are clarity, concision, and results correlated with the clinical situation.
Leclère
J
J
Département d'Imagerie, Service d'Echographie, Institut Gustave Roussy, Rue Camille Desmoulins, 94805 Villejuif. leclere@igr.fr
Leclère
C
C
Ollivier
L
L
D008499:Medical Records / Q000592:standards*; D011859:Radiography