One of the key components of the medical field is 'Radiology.' It is also considered to be one of the most harmless ways of diagnosing and monitoring a disease or injury. It uses ionizing and non-ionizing radiation for the same through imaging techniques such as x-ray radiography, computed tomography (CT), nuclear medicine, magnetic resonance imaging (MRI), and positron emission tomography (PET). The radiology report minimizes the risk of errors, and influences the methods of diagnosis and treatment.
One of the most significant constituent of the service offered by a radiologist is the radiology report. In the medical world, no documentation implies not done. Hence, for optimal reimbursements and apt treatment, apart from coding essentials, documentation/reporting is equally imperative. The radiology report typically includes patient demographics, location of the examination conducted, referring practitioner/healthcare provider, patient's medical history, name and type of the examination, date and time of the examination, the results of the radiology test/study/procedure, and the reasons for the study. It also includes the medical requirement of the study, limitations of the study, the extent of the exam (limited/complete), the number of tests taken, the angles/parts of the body, and if any usage of any other media or radiopharmaceuticals used. Other reporting requirements include the usage of specific medications, their route and concentration, and devices such as catheters etc if used need to be mentioned. Others aspects include description of each study performed along with a comparison to previous reports, known complications, any reference for follow-ups suggested, patient reaction (if possible), including all the findings and conclusions, and the date and time of dictation/transcription.
The radiology report is regarded as a part of the medical documentation of the patient. As per the requirements set by ACR, the report must include the answers to clinical questions as much possible, critical findings and the person who should be notified of the same along with the date and time, in addition to the radiologist's signature. Also, the diagnosis could be specific or differential as appropriate.
The practices as well as radiologists must maintain a record of each study at their end. The radiology reports must be clear, understandable and concise. They must be communicated at all times to the practitioner and patient. Ambiguous terms must not be used as the recipient of the report is the patient too. The written report of the radiologists' understanding, discussion and inference must be relevant and comprehensible while informing the condition/diagnosis/procedural results.
The radiologist must include the 'title' of the report for an understanding of the study/test conducted. Sometimes, the reason or the 'indication' for the examination conducted needs to be a part of the radiology documentation. This is also required by Medicare, ACR and some other third party insurance payers. The indication is usually a basic and brief statement of the cause of the diagnosis/clinical information. This could thus enhance the understanding and clarification of the clinical questions posed. This information could also be gathered from the patient (chart) or the referring physician.
Many radiology reports also contain the 'procedure' of the examination conducted on the patient. The procedure section includes: technical constraints, patient consent, drugs and isotopes. Coverage of invasive procedures is also a component of radiology reports. Another section known as the 'findings and discussion' details the clinical information, previous studies and the description of the present studies conducted. This section must be consolidated. There could be some details of 'positive findings' if any abnormality is found in the study; and is known as 'pertinent negatives' if there are normal findings and they counter the presence of abnormalities. Findings usually use pathologic, anatomic and radiologic terminology for description, and include factors that limit the study.
The 'impression' section is the most frequently read/significant part of the radiology report. It contains the summary/conclusion/diagnosis of the report. Statements can be numbered here, and could entail phrases throughout the report. It also includes suggestion for further assessment. The final report must be proofread and include electronic/rubber stamp signatures. Sometimes, for immediate needs for patient management/practice environment, a preliminary report can be rendered though it usually does not have all the sufficient data as found in the final report. It is a good policy to add a postscript at the end of the radiology report if it takes the form of phone, fax or email.Back