Radiology Reports

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