THE RADIOLOGIC REPORT - A REALISTIC APPROACH

The radiologic report records all of the important steps taken in the practice of radiology and should be evaluated with special interest. T he literature reflects the subjectivity inherent to a field left to pe rsonal interpretation, and few prospective studies of radiologic repor ting are available. To determine the characteristics of the ideal radi ologic report, the authors held workshops with two groups of radiologi sts and residents in radiology. The following items (in order of prior ity) were considered of prime importance by the participants and are d iscussed here: expression of an opinion and presentation of a workable differential diagnosis; an answer to the referring physician's questi on; a list of the limitations of the examination, if any; open-ended r ecommendations to the referring physician; integration of the findings with the clinical context; a synthesis of the findings obtained with various imaging modalities, when pertinent; and a complete description of the findings. The radiologic report has been compared to a scienti fic paper, and this comparison suggests the format for bringing these items together. The resulting realistic blueprint for the ideal radiol ogic report can be tailored to fit every imaging situation. Moreover, it can be a useful tool for evaluating the whole imaging process.