Enhancing the value of radiology reports: a primer for residents

Abstract

Purpose

The radiology report is the primary work product of the diagnostic radiologist. Its quality is a direct reflection of his or her knowledge, experience, and confidence. Certain factors hindering one’s ability to deliver a diagnostically accurate and concise report are sometimes unavoidable (e.g., study limitations and insufficient history); however, radiologists who routinely produce deficient reports not only erode their credibility and reputation amongst colleagues, they magnify their risk of litigation.

Methods

This article is directed toward radiology residents to help facilitate the adoption of effective reporting habits.

Results and conclusion

Up to 92% of referring physicians and 95% of radiologists agree that learning to report should be an “obligatory and well-structured” component of radiology residency education as discussed by Bosmans JM, Weyler JJ, De Schepper AM, and Parizel PM. Unfortunately, this remains the exception rather than the rule. This article is written with the following objectives: (1) to identify strategies that improve the value of radiology reporting, (2) to define the features of a high-quality radiology report, (3) to instill trust and respect from referring clinicians through clear, accurate, and effective communication, and (4) to understand and avoid potential medicolegal ramifications of deficient radiology reports.

Appendix

General terms to avoid.

Unnecessarily lengthens the report without changing the meaning.

• (No) evidence of, there appears to be, appears to represent, appearance of, a finding is seen

• Please note…, of note…, there is again noted…, there is again redemonstration of…, …are identified, …are visualized, …are seen, …a finding is seen, and …is remarkable for

• For comparison findings, use stable/increased/decreased with certain rules below

Implied.

• (No) radiographic/sonographic evidence of

• Post-contrast images show… and 3D TOF images show…

• There is no diffusion restriction…period

Redundant or incorrect anatomical descriptions.

• Bilateral lungs, kidneys, adrenals, orbits, etc.

• Lung “fields” – a classic pet peeve among chest radiologists and pulmonologists

• Describe the specific lobe, when possible

• “Overlies/overlying”

• CT (inappropriate): Can be taken literally

• XR (inaccurate/confusing): “there is a pleural effusion overlying the left lower lobe.”

• Alternative: projects over

• “No focal masses or lesions.” (The difference is?)

• “No pulmonary nodules or masses.”

• If there are no pulmonary nodules, there are, by definition, no pulmonary masses

• Oval in shape, close in proximity, small in size, slightly anechoic, interval change, previous exam of ___, abnormally dilated, time period, direct comparison (vs indirect comparison?)

  Vague qualitative, judgmental, or quasi-statistical words without explanation or specific measurements to justify.

• Quite, some/somewhat, good, satisfactory, acceptable, greatly, abundant, prominent

Silly or awkward.

• Gross/grossly: no”gross” adnexal mass

• Often used to make a broad distinction or the presence/absence of something obvious

• If overused → you appear incompetent

• Misinterpretation → patient thinks she has something vulgar or disgusting going on

• Using the word “stable” in neuro and MSK

• “Stable hardware loosening”, “stable 3-column C-spine fx”, “stable trimalleolar fracture”

• Alternative: unchanged

Using descriptors without a frame of reference.

• E.g., “there are increased interstitial opacities.” Increased vs normal? Increased since last study?

Miscellaneous.

• Inhomogeneous: in other words, heterogeneous?

• Echotexture vs echogenicity

• Echotexture = homo/heterogeneous, coarse, nodular etc.

• Echogenicity = hyperechoic/hypoechoic/anechoic

• There is an echogenic ____. How “echogenic?” All structures are echogenic!

• “No mass in ___” on noncontrast CT; use with care

• “Blush” without specifying as to etiology

• Hypervascularity of neoplastic vessels? Shunt? Active extravasation?

• No “depressed” skull fracture

• Does that leave the possibility of a nondepressed fracture?

• Can the imaging protocol be optimized to improve the detection of nondisplaced fractures

• Strangulated vs incarcerated

• Strangulated = ischemic

• Incarcerated = non-reducible (clinical term only)

Terms to avoid—chest.

No “sizable” or “obvious” pneumothorax (PTX)/pleural effusion.

• Focuses the fault on you—an admission that you are unwilling or unable to diagnose anything smaller than the largest of PTX/ effusion

• Alternative: no detectable PTX/effusion, no measurable PTX/effusion (use sparingly, e.g., on the most limited supine CXRs)

• Shifts the limitation from YOU to the STUDY

“The central airways are patent. No endobronchial lesion.”

• What is “central”?—subjective

• Are you looking at the 10th order bronchial lumen for a mucus plug?

“Pulmonary Vascular congestion”.

• Vascular distention without indistinctness? → pulmonary venous hypertension

• Vascular distention with indistinctness? → interstitial edema

“Infiltrate”.

• Airspace infiltrate? Interstitial infiltrate? Both?

• Infiltrating (“lepidic”) malignancy? → bronchoalveolar cell adenocarcinoma

“Azygos lobe”.

• Not a true lobe. Results from interrupted migration of the azygous vein. No isolated bronchovascular anatomy.

  Terms to avoid—musculoskeletal.

  “The soft tissues are unremarkable.”

• Most patients are presenting with trauma, swelling, or pain associated with both

• Therefore, you will be wrong 99% of the time!

• Tell them what you do know → no radiopaque foreign bodies or soft tissue gas

Soft tissue “air”.

• Air implies a benign process, iatrogenic, or penetrating trauma

• Gas → air, nitrogen (DJD, vacuum disc, osteonecrosis), or gas-forming infection

“Hip fracture”.

• Joints dislocate. Bone fracture.

  Joint spaces are “well-maintained” on non-weight-bearing images.

• Joint space narrowing only can be assessed on standing views

  “No acute fracture or malalignment” on spine XR or CT.

• Yet there may be degenerative antero/retrolisthesis

• Preferred: “No acute fracture or traumatic malalignment; however, there is a grade 1 anterolisthesis of L4 on L5.”

“No joint effusion or lipohemarthrosis”.

• If there is no joint effusion, then by definition, there is no lipohemarthrosis