The Radiology Report

Abstract

The radiology report must communicate the results of imaging studies to the healthcare team in a clear, accurate, and timely manner - combining the radiologist’s medical knowledge, experience, and medical judgment to communicate their observations and form a summary impression of their findings. The key elements of a radiology report are 1) Administrative information, 2) Patient identification, 3) Clinical history and indications for the examination, 4) Imaging technique, 5) Comparison with prior studies, 6) Observations / Imaging findings, 7) Summary or Impression, and 8) Signature. These elements form the basis of “structured reporting”, a communication technique endorsed by the American College of Radiology (ACR).In structured reports of thoracic imaging studies, imaging findings are organized as separate paragraphs: 1) tubes and lines, 2) lungs and airways, 3) pleura, 4) heart and mediastinum, 5) bones, and 6) soft tissues. This format is preferred by clinicians, as information pertaining to specific organ systems can be retrieved and compared to previous reports more easily.