GUIDELINES ON HOW TO OR HOW NOT TO WRITE A RADIOLOGY REPORT

REPORT STYLE GUIDELINES

ONLY ABSTRACT (FULL ARTICLE AT-http://www.radiology.ucsf.edu/instruction/abdominal/ab_handbook/02-ReportGuidelines2.html)

As far as possible, a uniform “style” is desirable for our radiology reports, because it prevents discordances in terminology between reports and portrays the section as a group of like-minded radiologists. This guide is a brief outline of desirable common features for our reporting terminology. This guide addresses “style”, as distinct from “content”. The radiology report is a formal medicolegal document that is often the primary means of communication between radiologist and referring physician, and therefore the terminology should be concise, clear, and pertinent.

Some very interesting points from the article-

The term “is evidence of...” should only be used for findings which are inferred and not directly observed. E.g., “No evidence of portal venous hypertension”. Conversely, it is inappropriate to say “no evidence of pleural effusion”, since the phrase “no pleural effusion” is preferable.

Avoid the adjective “significant”. E.g., “No significant adenopathy” – does this mean there is insignificant adenopathy?

Use the active rather than the passive tense. E.g., “The pancreatic head mass obstructs the common bile duct”, rather than “The pancreatic head masses causes obstruction of the common bile duct”.

The phrase “cannot be excluded” should be avoided as far as possible; it is a grammatically undesirable double negative, and is used differently by radiologists. E.g., stating “spiculated 4 cm lung mass, bronchogenic carcinomas cannot be excluded” when the actual intended meaning is “spiculated 4 cm lung mass, bronchogenic carcinoma is likely”. When a diagnosis is mentioned, but considered unlikely, other options are to state “x is a remote possibility/consideration” – this expresses the intended meaning without using an unwieldy double negative.

And many more practical points--

FULL ARTICLE -

REPORT STYLE GUIDELINES

http://www.radiology.ucsf.edu/instruction/abdominal/ab_handbook/02-ReportGuidelines2.html