The Perfect Radiology Report
For the greatest impact on patient care, radiologists must write clear and concise reports.
It might be tough to imagine now, but referring physicians used to visit radiology reading rooms daily to review film-based images and talk with radiologists about exam findings.
By the end of these consultations, referring clinicians had all of the information necessary to treat their patients. Radiologists would later dictate their findings in written reports, which would be typed, edited, finalized, and signed days later, mostly as a formality. “The radiology report would go directly into the medical record, and no one would ever read it, at least not as part of that particular episode of care, because all of the critical communication had already taken place in person,” says Michael A. Bruno, MD, FACR, professor of radiology and medicine and vice chair for quality and safety at the Penn State Milton S. Hershey Medical Center.
But in the late 1980s, that all began to change with the introduction of digital imaging. Once referring physicians could access imaging studies electronically from their own offices through PACS, they stopped going to radiology reading rooms. Now the best chances (and in some cases the only chances) radiologists have to communicate their interpretations and recommendations to referring physicians is through their formal written reports, notes Bruno, who is also chief in the division of emergency radiology at Hershey Medical Center and co-creator of a report writing workshop that he delivers to residents at his and other institutions. “If the report is unclear and poorly written, then we will have failed to add value to the patient’s care,” he says.
Radiologists must do everything they can to provide added value as health care’s pendulum swings toward quality. In part, this means producing reports that are easy to understand and digest. Proper grammar and correct spelling, definitive words and phrases, descriptive language, and logical organization are essential. “Our reports should not only be thorough but also direct, clear, and concise so that the referring physician understands the information and patient care is optimized,” says Pamela T. Johnson, MD, associate professor of radiology and diagnostic radiology residency program director at Johns Hopkins Medicine in Baltimore. “We must make every effort to add value to the patient’s care by creating well-organized reports that identify the important abnormalities and direct the physician to the best management for the patient.”
While producing clear and concise reports is more important than ever, many radiologists have difficulty writing succinct reports. The reason is summed up by a famous Mark Twain quote that says, “I didn’t have time to write a short letter, so I wrote a long one instead.” It may seem counterintuitive, but it’s often more challenging to write concisely than it is to produce long, rambling documents. “It’s easier to write 300 words quickly than 50 words that eloquently convey the information you want to share,” explains Samson Munn, MD, vice chair of quality and core operations in the radiology department at Tufts Medical Center in Boston and a contributor to the Speaking of Language column in the JACR®. “Writing for brevity is hard, but it’s a skill that can be learned with practice.”
Before radiologists put fingertip to keyboard, however, they must determine what information they want to include in their reports. “You should ask yourself four questions: what do I see on the images, what do I think the findings mean, what do I want the referring physician to conclude from my report, and what do I think the referring physician should do next,” says Leonard Berlin, MD, FACR, radiologist at Skokie Hospital and professor of radiology at Rush University and the University of Illinois, Chicago. Radiologists should organize this information into a streamlined format that guides the referring physician to the next step in the patient-care process. “Our primary audience is referring physicians who have limited time, so our reports must get to the point and be organized to ensure referring physicians can find the information they need quickly and easily and refer to it again, as needed,” Bruno says.
Some radiology practices are moving toward structured reports to help radiologists organize their writing, but most practices continue to use prose for at least a portion of their reports. Radiologists should break these sections into short paragraphs, which are easier to read than long blocks of text, says Jenny K. Hoang, MBBS, associate professor of radiology and radiation oncology at Duke University Health System and a contributor to the JACR Speaking of Language column. “Many clinicians don’t read the bodies of our reports, and that’s not surprising given that these sections are usually too wordy and poorly formatted,” she says. “We should list the most critical findings at the top and use paragraphs to separate findings into groups.” Hoang also recommends crafting distinct findings and impression sections, so that the impression offers an interpretation of the findings rather than simply reiterating the findings. “These are two separate sections in the report and should not be the same,” she says.
As radiologists write their reports, they should choose their words carefully. Using words incorrectly can cause confusion and have unintended legal consequences. For instance, Munn recommends avoiding the word inadvertently, which most people think means “accidentally.” But the primary definition, according to some dictionaries, is “not duly attentive.” “In court, the lawyer will hand you a dictionary and ask you to read the first meaning of inadvertently,” Munn says. “Then as you try to explain that you meant that the missed finding happened accidentally and not because you weren’t looking, they’ll say, ‘Do you give as much attention to your technique in performing procedures as you do to your word choice, doctor?’ And regardless of whether you answer yes or no, you’re in trouble.” For that reason, Berlin suggests treating every report like a potential legal document. “You never know when a report, several years later, may be magnified and projected on a large screen in a courtroom, where every word and punctuation mark will be highlighted and scrutinized in detail by a judge and a jury,” he notes.
Radiologists should also avoid using ambiguous phrases, such as “cannot exclude” and “correlate clinically,” without a detailed explanation. “If you say ‘cannot exclude’ without explaining why you cannot exclude the diagnosis or what can be done to exclude the diagnosis, that’s basically a copout,” Hoang contends. “Similarly, if you simply say ‘correlate clinically,’ you’re putting the onus on the clinician to interpret the findings. Instead, you should review the patient’s medical records to see whether the diagnosis you’re considering actually correlates clinically with the patient’s history. Then state whether the diagnosis can be correlated clinically or not in the report.” Other phrases that radiologists should swap for more descriptive terms include “no bulky adenopathy,” “ill-defined,” and “epicenter of the mass.” “We should describe findings in enough detail that someone who is not looking at the image would be able to draw a picture of the image based on our words alone,” Munn says.
While radiologists should avoid certain words and phrases in their reports, under no circumstances should they ever include comments that are critical of their clinical colleagues. For example, a radiologist should never write that a study was unnecessary or inappropriate in a report. “Reports should never contain critical comments because those comments could be held against the radiologist or somebody else down the road,” Berlin says. “We are obligated to include the results of a comparison explicitly in our reports only if the results are clinically appropriate or warranted,” he says. “When appropriate, leaving the discussion of the actual results of the comparison out of the current report is often wise.”
As radiologists craft their reports, they should follow the grammar rules they learned in elementary school. Appropriate punctuation, correct spelling, and good sentence structure are just as important for radiology reports as they are for the great American novel, if not more so. If novelists use poor sentence structure, a publisher might reject their manuscripts. But if a radiologist uses poor sentence structure, it could confuse the referring physician and have a negative impact on patient care. “The radiology report is a crucial piece of information for the patient, not only for the current examination but also for future examinations,” Berlin explains. “Like the rest of the medical record, it’s a sacred document, and it should be written so that anyone can understand it at any time.”
Writing clear reports is particularly important now that patients are accessing their reports. Johnson says radiologists should word their reports with this new audience in mind. “You still want to use medical terminology,” she says. “But you should refrain from elaborating on insignificant findings that could cause patients unnecessary alarm.” Bruno agrees, saying that patients will look up medical terms they don’t understand, but they have no easy way of knowing whether a finding is important or not unless it’s explained in the report. “It’s another reason to keep the extraneous stuff out of our reports and really get to the point,” he says.
Radiologists who want to improve their writing skills can consult any of the scores of writing books on the market, including Strunk and White’s long acclaimed “The Elements of Style.” For those who want to learn how to write better reports in particular, Bruno has created a report-writers workshop, which he co-presents to residents at Hershey Medical Center annually and to other groups upon request. “It’s a hands-on workshop where participants edit bad reports that were actually signed and sent to referring physicians; then the whole group comes together to discuss the reports and their edits,” Bruno explains. “This instantaneous feedback is really helpful for learning.”
While writing clear and concise reports takes a great deal of effort, the return is worth the investment. “The goal is to be the radiologist that referring doctors call all the time because they respect your opinion and they respect your abilities,” Johnson says. “And the only way you’re going to gain that respect is through your reports. It’s your signature, so choose your words and your content carefully. If you consistently produce well-organized, accurate, and meaningful findings reports, you will become a true partner in patient care.”
Get the latest on images in radiology reports at the ACR 2016 session “Image Exchange: Where We Are and Where We Are Going.”
By Jenny Jones, Imaging 3.0™ content specialist