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The Radiology Report

  • Haris Chrysikopoulos
Chapter

Abstract

I define the radiologic report as a medicolegal document that binds the reader to inform, guide, respect, and protect both the patient and the referring physician. Thus the way we construct or dictate our report should satisfy the requirements above, of course within the constraints of uncertainty of each individual case. By “information” I mean the answer to the clinical question, and the inclusion of other, significant or incidental findings. By “guidance” I mean our recommendations (if indicated) for further workup. By “respect” I mean two things: (a) providing true value to the referring physician, instead of recommending “clinical correlation,” which he does anyway, and (b) not harming the patient through words or phrases that may crush his self-esteem. A clear report with specific recommendations (a) protects the patient from being subjected to inappropriate or potentially harmful tests, contrasted to a vague, incomplete report that would justify a continued, potentially misdirected search for a diagnosis, and (b) protects the referring physician from overlooking significant findings that if ignored could lead to adverse outcomes and accusations of negligence. Careful and appropriate selection of words and language are absolute requirements to avoid confusion and misunderstanding by the referring physician and the patient, when they read our report. Our level of confidence should be transparent, moderated by “common sense,” and not masked by statistical hedging. The preparation and timely delivery of a worthy report are indeed acts of deep respect to the patient, the referring physician, and to ourselves. This chapter addresses all properties of a valuable report that can truly benefit the patient.

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Copyright information

© Springer Nature Switzerland AG 2020

Authors and Affiliations

  • Haris Chrysikopoulos
    • 1
  1. 1.CT & MR DivisionEurodiagnosis Imaging CenterCorfuGreece

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