Precision and accuracy are crucial in the field of medicine.
Standardized vocabulary and medical terminology help support effective and efficient communication among healthcare professionals, facilitating the unambiguous transmission of complex medical concepts, conditions, treatments, and procedures. Radiology reports, in particular, rely heavily on this standardized language. And while the abundance of technical terms, abbreviations, and acronyms may be perplexing for those of us without a medical background, they create a vital bridge between radiologists and multidisciplinary teams involved in a patient’s care.
Radiology reports aid in developing effective diagnostic and treatment strategies tailored to a patient’s specific needs. They’re used to evaluate changes in a patient’s condition. And they help track the effectiveness of therapies. Though primarily intended for referring providers, understanding our radiology report’s basic structure and key terms can help alleviate some confusion. This knowledge can empower us to ask questions and initiate valuable conversations with our doctors.
Radiology Report Structure
While standardized guidelines exist, radiology reports can differ between institutions based on a facility’s established protocols. For example, certain institutions may incorporate additional sections based on their internal workflows and referring physician preferences. The specific requirements for each subspecialty or imaging modality, such as oncological imaging or mammography, may also vary from practice to practice.
These factors often influence the level of detail provided in a report. Some institutions may prefer concise reports focusing on essential findings, while others may include more detailed descriptions or additional information to aid clinical decision-making. A radiologist’s experience and specialty training may also impact the thoroughness
of a report. Despite the variability, certain common elements are typically in all radiology reports to ensure clarity and consistency.
Understanding the Main Sections in a Radiology Report
Radiology reports typically include the following five sections: indication, technique, comparison, findings, and impression. Each serves an essential purpose in communicating the details and results of an imaging procedure.
Indication
A radiology report’s "indication" section provides a concise description of the clinical reason or suspicion that led to the ordering of the imaging study. It is a communication bridge between the referring healthcare provider and the radiologist interpreting the images.
Details typically found in this section include:
Patient Information: The patient’s name, age, and gender.
Clinical Indication: An outline of any symptoms or specific diagnostic questions the referring physician wants to address through the imaging examination. For example, "lower back pain," "evaluation of a suspected fracture," or "assessment of abdominal mass."
Relevant Clinical Findings: In some cases, the indication section may include relevant findings from the patient’s physical examination, laboratory tests, or prior imaging studies.
The indication section is crucial for radiologists, as it guides their interpretation and helps them focus on the specific clinical question at hand. By understanding the clinical indication, the radiologist can tailor their analysis and provide a more accurate and relevant report to the referring physician.
Technique
The technique section in a radiology report typically includes information about the imaging modality used, the specific imaging parameters, and any additional details relevant to the acquisition of the images.
Key elements commonly found in the technique section include:
Imaging Modality: The imaging technique employed, such as X-ray, computed tomography (CT), magnetic resonance imaging (MRI), ultrasound, or nuclear medicine study.
Imaging Protocol: Details of the imaging sequences or the specific views acquired during the study. For example, this section may specify the slice thickness or reconstructions involved in a CT scan.
Equipment: Information about the imaging equipment used, including the manufacturer, model, and relevant technical specifications, may be noted. This can be important for quality control.
Contrast Administration: If a contrast agent was used during the study, this section outlines the type of contrast (e.g., iodinated contrast, gadolinium-based contrast), the route of administration (intravenous, oral, intra-articular), and the timing of the contrast injection.
Limitations: The technique section may mention any limitations or challenges encountered during the study that could affect image quality or diagnostic interpretation. For example, patient motion, obesity, or poor breath-holding.
Radiology Report Example:
Multiplanar multisequence MR imaging was performed of the brain and IACs with and without contrast.
Comparison
The "comparison" section in a radiology report provides information about any previous imaging studies available for comparison with the current study. The type of imaging modality (e.g., CT, MRI, X-ray) and the date of the previous study will be specified. This section will also state whether there are any limitations or challenges in comparing the current study with prior images, such as different imaging techniques, incomplete or unavailable prior imaging reports, or significant time gaps between the studies.
The comparison section allows the radiologist to provide a more accurate assessment by considering the evolution of findings. It aids in diagnosis, evaluation of treatment response, and identification of new or changing pathology. Additionally, it helps the referring physician understand the significance of any changes in the imaging findings and guides subsequent management decisions.
Radiology Report Example:
Comparison made with previous cervical spine MRI dated June-17-2018.
Findings
A radiology report’s "findings" section contains a detailed description and interpretation of the imaging findings observed during the examination. It provides a comprehensive assessment of the patient’s anatomy, any abnormalities or pathologies detected, and their significance.
The findings section typically includes:
Anatomic Description: The anatomy visualized in the imaging study, including specific structures, organs, tissues, or regions of interest relevant to the examination.
Abnormal Findings: Any visualized abnormalities, pathologies, or variations from the expected normal anatomy. Each finding is described in detail, including its location, size, shape, density, signal characteristics, or other pertinent features.
Radiology Report Example:
Lungs: Scattered centrilobular ground-glass nodules, most prominent in the right middle lobe.
Pleural space: Unremarkable. No pneumothorax. No effusion.
Heart: Unremarkable. No cardiomegaly. No pericardial effusion.
Read Next: What "Unremarkable" Means In a CT Scan Report
Impression
A radiology report’s "impression" section provides a concise summary and interpretation of the imaging findings. It is the final part of the report intended to convey the radiologist’s overall assessment of the study.
The impression may include:
Summary of Findings: A summary of the key findings observed during the imaging examination, such as significant abnormalities, areas of concern, or clinically relevant findings that are important for the referring physician to consider.
Diagnosis: The radiologist may state in the impression section if a specific diagnosis can be confidently made based on the imaging findings. This is particularly true when the imaging features are highly characteristic of a particular condition or pathology.
Differential Diagnosis: In cases where the diagnosis is uncertain, or there are multiple possible explanations for the findings, the radiologist may provide a list of potential diagnoses. This helps guide further investigations or consultations with other specialists to narrow the possibilities.
Clinical Correlation: If applicable, the radiologist may relate the imaging findings to the patient’s clinical presentation or history.
Recommendations: If further imaging studies, procedures, or consultations are warranted based on the imaging findings, the radiologist may provide specific recommendations. This helps guide the referring physician in subsequent management decisions or additional investigations.
Radiology Report Example:
Scattered centrilobular ground-glass nodules are more prominent in the right middle lobe. Differential diagnosis includes hypersensitivity pneumonitis, respiratory bronchiolitis, endobronchial spread of infection (TB, non-tuberculous mycobacterial infection, aspergillosis).
Still have questions about your radiology report?
Here are some steps you can take to get the answers you need.
Discuss the results with your referring provider.
Scheduling an appointment to discuss imaging findings with your referring provider is highly encouraged. Your doctor’s office should facilitate the scheduling, but you can also request an appointment. Our doctors play a vital role in helping us understand our radiology reports by explaining the findings in less technical terms; an in-person or virtual meeting is an excellent opportunity to address your questions.
Get a subspecialty second opinion.
A second opinion from a subspecialty radiologist is an opportunity to equip you and your doctors with more information. It can help alleviate concerns about a missed diagnosis or misdiagnosis. It can help you and your doctors make confident decisions about your health. And it can provide peace of mind before an operation or treatment.
Subspecialty radiologists are deeply familiar with the nuances of imaging in their respective areas of expertise. Getting a second set of eyes on your images will empower you with additional insight. If a subspecialist did not initially read your scan, a second opinion is especially valuable.