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Radiology Reports

  • Ronald L. Eisenberg

Abstract

Written interpretations by radiologists of imaging studies are extremely important from both the medical and legal perspectives. They are an integral part of the medical record and an essential link between the diagnosis and treatment of a patient’s illness.1 The radiology report should accurately and concisely describe the positive imaging findings and any relevant negative findings, as well as provide an opinion as to their significance.2 If there is a specific clinical question presented in the request form, the report should attempt to answer it clearly and directly. Whenever possible, there should be a differential diagnosis with relative probabilities. As the American College of Radiology (ACR) Standard for Communication3 notes, when appropriate the radiology report should contain an impression including “a precise diagnosis” and a recommendation for “follow-up or additional diagnostic studies to clarify or confirm the impression.” A rambling description of findings without a reasonable conclusion may only leave the reader confused.4 The length of the body of the report depends on the number of findings, whereas the length of the conclusion reflects the ability of the radiologist to make sense of the findings.5

Keywords

Radiology Report Legal Liability Malpractice Suit Health Care Financing Administration Additional Imaging Study 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

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Endnotes

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Copyright information

© Springer-Verlag New York, Inc. 2004

Authors and Affiliations

  • Ronald L. Eisenberg
    • 1
    • 2
  1. 1.Department of RadiologyAlameda County Medical CenterOaklandUSA
  2. 2.University of California School of Medicine at San Francisco and DavisUSA

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