Although the accuracy of the interpretation of a radiology exam is the ultimate criteria on which radiology quality is judged, the most visible evidence of that interpretation is the radiology report. For the vast majority of cases, the report serves as the sole method by which the results of the exam are communicated to the referring physician and the patient.
American College of Radiology Guidelines
The American College of Radiology (ACR) offers clear guidance the format and content of radiology reports in the ACR Practice Guideline for Communication of Diagnostic Imaging Findings. As stated in their introduction, “Effective communication is a critical component of diagnostic imaging. Quality patient care can only be achieved when study results are conveyed in a timely fashion to those responsible for treatment decisions. An effective method of communication should: (a) be tailored to satisfy the need for timeliness, (b) support the role of the interpreting physician as a consultant by encouraging physician communication, and (c) minimize the risk of communication errors.”
Ensure Correct Patient Identification
To ensure that the results are given for the correct patient, every report must include specific demographic information. This includes the name of the patient with any additional identifying information, the name of the facility where the exam was performed, the type of exam, the name of the referring physician, and the date and time that the report was generated.
History and Technique
Any provided clinical history and/or the reason for the exam should also be documented in the report. Specific imaging techniques, including the use of contrast media (type, amount, and route of administration) should also be listed.
Where’s the Beef?
The “meat” of the report, where the results of the interpretation of the images are documented, is in the Findings and Impressions sections, and will be discussed in my next blog.
How often do you review the ACR guidelines?
