Writing an appropriate radiology report is a critical task for radiologists, since the report documents the results of a radiologic study or procedure and serves as a legal document. Yet, too little attention is given to proper report format or content, despite the fact that “failure to effectively communicate results” is a major cause of malpractice litigation against radiologists. The author reviews radiology report components and suggests appropriate standardization.
is an Interventional Radiologist, East Texas Radiological
Consultants, Athens, TX.
The written radiology report is the most critical component of
the service provided by a radiologist. It constitutes the formal
documentation and communication of the results of a radiologic
study or procedure.
The reports are usually dictated by a trained radiologist, but
reports may vary greatly in style, format, and effectiveness. A
major cause of litigation against radiologists is failure to
effectively communicate results.
As radiologists, it is time that we look at this issue with renewed
Part of the problem with radiology reports arises because we do
not really understand how important this document has become to the
This lapse is more understandable when you realize that most major
radiology textbooks do not address the subject of report
composition. This would be equivalent to a journalism textbook
without a chapter on how to write an article. But journalism and
radiology have a lot in common. Both professions require spending a
great deal of time gathering "facts" and "data" and then reporting
that material in written form for a reader.
The purpose of this article is to help radiologists improve the
quality of their written radiology reports by reviewing the
components of a report, addressing grammar and writing style, and
considering appropriate standardization.
One of the 3 most common reasons for malpractice suits against
radiologists is failure to communicate results clearly and
Poor communication is a common reason patients choose to sue the
In some situations, such as mammograms, it is helpful to give a
copy of the report directly to the patient, which makes it even
more important that the report is clear and understandable.
If a report is written so that a patient can understand what is
said, it is much more likely that a healthcare provider, who
depends upon the report to make decisions concerning patient
management, will also understand the report.
In order to achieve clear communication, the radiologist should
be aware of the intended reader of the report and how that reader
will understand what is written. Most often, the reader of the
radiology report is the individual responsible for providing direct
patient care. In some cases, the reader will be the patient. The
report should be written with these readers in mind.
The use of difficult or ambiguous terms should be avoided. Esoteric
terms and language not commonly understood will detract from
The radiology report may provide information critical to patient
care, but these findings can be helpful only if the reader
understands what is said. Unfortunately, the proper use of grammar
becomes a part of understandable communication.
Table 1 lists some guidelines that can help radiologists create an
Effective report writing means that useful information obtained
from the radiologic study will be transmitted clearly, concisely,
and unambiguously. The report is the written communication of the
radiologist's interpretation, discussion, and conclusions about the
radiologic study. The written report is frequently the only source
of communication of these results. The report should communicate
relevant information about diagnosis, condition, response to
therapy, and/or results of a procedure performed.
The written report should also answer any clinical question
raised by the requesting patient-care provider that is relevant to
the radiologic study. For example, if the study was requested with
the clinical information "cough and fever," then the report should
specifically address whether or not the findings are consistent
Ownership of the radiology report, its legal status, and its
relationship to malpractice liability is sometimes misunderstood
and can contribute to a confusing report. Ownership of the written
report is held by the organization providing the radiologic
service; this organization may be a hospital, clinic, health
maintenance organization, imaging center, or private radiology
office. Maintenance and security of the original record is the
responsibility of the organization or individual who performed the
imaging examination. Since the passage of the Health Insurance
Portability and Accountability Act of 1996 (HIPAA), all patients
have a legal right to a copy of their report.
The radiology report may generally be viewed as part of the
medical record. The Joint Commission on Accreditation of Healthcare
Organizations (JCAHO) considers the radiology report to be part of
the medical record because it documents the results of a radiologic
test or procedure.
In addition, hospitals have specific policies regarding the
radiology report as part of the medical record. If the medical
record is subpoenaed or when statutory regulations require specific
documentation, the medical record can be regarded as a "legal
Malpractice suits are based on either damages or
breach-of-contract issues. The most common cause of malpractice
suits against radiologists is "failure to diagnose."
Failure to diagnose may become the basis of malpractice if this
failure is the proximate cause of injury or damages.
The failure to diagnose may be the direct result of the written
report. The second most common cause of malpractice suits against
radiologists is "failure to clearly communicate the results."
The report can be the proximate cause of damages if it failed to
effectively communicate important information about the patient's
It is this aspect of liability risk that should also motivate
radiologists to look at their reports as "communications" to
referring physicians and patients and to compose them
The key to a clear and concise radiology report that will
provide reliable high-quality communication is a coherent format.
The radiology report is a diagnostic test result that should stand
independent of the individual interpreting radiologist. The quality
of the report should not vary as a result of there being different
interpreting radiologists. This is a key principle in statistical
quality control. The control of variation reduces liability risk
because it ensures that important issues are addressed
Using a standard format will significantly improve the ability of
the report to communicate effectively. Variations in the report
format create confusion for the reader, whereas a consistent
location for the results, discussion, and conclusions assists the
reader in understanding the report and its clinical
The scientific report format is a practical choice for the
This format is used by major scientific journals, is familiar to
most physicians, and follows the general outline recommended by the
American College of Radiology (ACR).
It also supports the notion that the radiologic study is a
"scientific test." Table 2 presents a side-by-side comparison of
the scientific report format and a corresponding radiology report
In most situations, the title of the radiologic report is
already standardized. In some institutions, this title is provided
to the transcriptionist with the request. However, it is customary
to include the report title for the purpose of identification. The
name of the study that is used during ordering or scheduling the
study may not be the desired title for the official report. The
correct title of the study actually performed should be clarified
at the time of dictation. Complicated procedures, such as
arteriograms, biopsies, or drainage procedures, may require a
statement of the title at the time of report dictation.
With many standard studies, a stated indication, or history, is
not necessary in the written report. Requirements for an
appropriate indication for a "test" do not necessarily require
documentation of that indication within the report. In some
institutions, the indication, or reason for the examination, is
part of the request for the study and is automatically included in
the heading of the report. However, this information may or may not
represent the true indication for the study. As the consultant, the
radiologist is responsible for determining the appropriateness of
the study. Often, the real reason for the study is determined from
information from the patient's chart or from a verbal discussion
with the referring provider. Therefore, recapitulation of the
indication for the study at the time of the report dictation is
appropriate because it will document the actual reason the study
In addition, many third-party payers and Medicare now require an
appropriate indication before they will reimburse for a study.
Therefore, the radiologist is responsible for ensuring that the
study was performed for an appropriate reason. The ACR Standards
also include this requirement and even suggest including the
corresponding ICD-9 diagnosis code in the report.
This can greatly expedite billing.
The indication should be a simple, concise statement of the
reason for the study and/or applicable clinical information or
diagnosis. A clear understanding of the indication may also clarify
appropriate clinical questions that should be addressed by the
study. For example, a chest radiograph requested for "cough and
fever" implies the question, "Does this study indicate the presence
Even without a stated reason for the study, it is the
radiologist's responsibility to identify the appropriate
indication. This may be as simple as the recognition of the implied
indication as understood by the context of the study and does not
necessarily need to be included in the report. This information may
also be available from the patient, the patient's chart, or the
referring provider. This information should be pursued with
reasonable thoroughness, as it may significantly change the focus
of the study.
Every radiologic study has a procedure associated with
performing the examination. For most routine studies, the procedure
is implied by the title. For example, a routine study such as a "PA
& LAT Chest," by accepted use, implies the procedure
(posteroanterior and lateral chest radiograph), and a separate
"Procedure" section of the report is not necessary. However, a
separate "Procedure" section may be convenient to document informed
consent, technical limitations, drugs, and isotopes or contrast
material associated with the study. Frequently, reports for
invasive procedures are best organized in a separate "Procedure"
Findings and discussion
The "Findings and Discussion" section of the report includes the
description of the results of the study, relevant information from
previous studies, pertinent clinical information, and any
discussion. The discussion should explain the relationship of the
results, previous studies, clinical information, and the reasoning
supporting the radiologist's conclusions. However, the statements
in this section should be clear and concise. Long, wordy reports
are less likely to be read by the intended reader.
Approaching the radiologic study as if it were a scientific test
will help limit the findings that need to be described. To do this,
we assume a "null hypothesis" or we anticipate that the findings
will fall within the expected range of normal for the given
population. Therefore, it is necessary to describe only those
findings that are abnormal and disprove the null hypothesis. These
are referred to as positive findings. The exception occurs when a
clinical question implies the possible presence of a specific
abnormality. This introduces a positive hypothesis that the
findings will document the questioned abnormality. In this case,
normal findings that refute the presence of the questioned
abnormality should be described and are referred to as pertinent
This section of the report must be organized in an orderly
format so that the reader will understand the basis of the final
conclusions and impressions. The reader should be able to find
support in the "Findings and Discussion" section for each item
listed in the "Impression" section.
The abstract is the summary of a scientific report. In a
radiology report, the summary has been referred to as the
"Impression," "Conclusion," or "Diagnosis" section. Sometimes this
summary is an impression, sometimes it is a conclusion or
diagnosis, and sometimes it is a concise statement of the findings.
Practice patterns seem to favor "Impression" for the name of this
section of the report.
In a large survey, >50% of referring physicians read only the
"Impression" section of a radiology report!
This places great importance on this section of the report and
emphasizes the need to view this section as a summary.
The common practice of using a numbered list for the
"Impression" section helps produce a concise summation. Numbered
statements or phrases should be ordered logically to make use of
implied ranking. Statements in the numbered list should maintain a
parallel structure-that is, if complete sentences are used, then
complete sentences should be used throughout the list, or if
phrases are used, then phrases should be used throughout. For
clarity, it is best to limit each numbered item to a single
sentence or phrase.
The "Impression" section is a list of summary statements that
includes both conclusions about the radiographic study and
recommendations for further evaluation and patient management.
Recommendations are appropriate if the radiologist is knowledgeable
about what is being recommended and if the recommendation will
improve the care of the patient. Recommendations are based on the
results of the radiologic study and the experience of the
individual radiologist. The range of appropriate recommendations
should be limited to the scope of knowledge of the individual
radiologist. The use of appropriate recommendations can greatly
contribute to the management of patient care and can provide
consultative information that may not otherwise be available.
However, the use of recommendations with the misguided notion that
it is effective risk management should be avoided.
The "Impression" section is the most commonly read portion of
the radiology report and is generally considered to be a summary of
the study. In addition, this section may be all that is required in
certain routine "normal" studies. Consequently, the "Impression"
section is the most important part of the radiologic report.
Footnotes to the report
Other, more timely forms of communication of the report are also
important to good radiology practice. Phone, fax, and email
communication of serious, time-critical, or life-threatening
information is becoming the standard of practice, and documentation
of these communications is good risk management. Since these forms
of communication are separate from the report itself, it is
convenient to use a postscript or footnote to document such
communication. A short postscript at the end of the written report
is sufficient. Here are some examples:
"P.S. Dr. Doctor was contacted by phone at 1300 on 1/1/01 and
the results discussed";
"P.S. Fax of report sent to Dr. Doctor";
"P.S. A copy of the report was sent by email to Dr. Doctor";
"P.S. Patient contacted by telephone and informed of results and
the need for follow-up."
The written radiology report is the critical service of
radiology and should provide clear and concise communication that
is understandable by the intended reader. Since increasingly more
often the patient is the reader of the report, it is even more
important to keep the report clear and concise. Additionally,
failure to clearly communicate results continues to be a leading
cause of delayed diagnosis and resultant lawsuits. It is time to
take a new and positive look at the radiology report from a
different perspective. Efforts to make the radiology report an
effective means of communication that is independent of individual
radiologists and that focuses on the intended readers can
contribute to both improved patient care and reduced liability