Four missteps in radiology reporting and how to avoid them
Every day, radiologists write reports communicating their findings from images to other clinicians. The exact language used might not seem like a big deal, but in these reports, a single word or phrase can make the difference between right care and wrong care.
In a paper just published in the Journal of the American College of Radiology, Right Care Alliance Radiology Council members Dr. Jill Wruble and Dr. Saurabh “Harry” Jha explain how common pitfalls in radiology reports can lead to overuse.
- The report is disorganized. A long and rambling report can make it difficult to find the key points in the report, causing confusion on what the next steps should be. Keep sentences short, and put the most relevant findings upfront.
- The conclusions are ambiguous. Radiologists are often tempted to write in reports that an unlikely diagnosis “cannot be excluded,” to absolve themselves of responsibility in the case that the diagnosis proves true. Phrases like this can lead to unnecessary additional tests and should be avoided.
- There is too much jargon. Don’t use technical terms when more common terms could be used. Even though the report is meant to be read by doctors first, patients should be able to understand the report if they choose to access it.
- Incidental findings are listed without guidance. Often scans pick up findings in other areas of the body, called “incidental findings.” Listing these findings without guidance can lead to a “cascade” of unnecessary testing. The report should say whether the incidental findings are of high importance and include a clear recommendation for next steps.