Table 3 Comparison of advice to radiologists regarding communication of imaging findings
Royal Australian and New Zealand College of Radiologists | Royal College of Radiologists (UK) | American College of Radiology | Canadian College of Radiologists | European Society of Radiology | Hong Kong College of Radiology | |
|---|---|---|---|---|---|---|
Purpose of the report | Not discussed | ‘The purpose of an imaging report is to provide an accurate interpretation of images in a format that will prompt appropriate care for the patient’ | ‘The final report is the definitive documentation of the results of an imaging examination or procedure’ | ‘The effective transmission of imaging information from the radiologist to the referring physician constitutes the main purpose of the report’ | ‘The written radiology report is the most important means of communication between the radiologist and referring medical doctor’ | ‘..the written radiology report constitutes the legal record of the radiology investigation or procedure’ |
Length | ‘Reports should be as concise as possible while still conveying the information required….’ | ‘Where there is a need for a long descriptive report, it should conclude with a short summary of key findings and their interpretation…’ | Not discussed | ‘The ideal radiology report is ….concise’ | ‘A balance needs to be struck between a clear description of the positive and negative findings and the concentration of the reader’ | ‘[The responsibility of the radiologist is to] '…ensure that the reports are….precise’ |
Templated or structured reporting | ‘Standardised examination/disease process-specific templates should be developed where they are likely to improve the quality of communication…’ | Not discussed | ‘Standardized computer-generated reports should be designed to satisfy the above criteria’ | ‘Standardized computer-generated template reports (or other structured report formats) that satisfy the above criteria are considered to conform to these standards’ | ‘[Structured reporting]…is more time efficient than dictation….has also been suggested to improve communication of radiology results…’ | Not discussed |
Terminology—referring clinician | ‘…should use terminology with widely understood and commonly agreed meaning among health care practitioners.’ | ‘The wording of the report is likely to differ when it is written to a general practitioner who may be unfamiliar with a relatively rare condition, compared with a specialist in that particular field’ | Not discussed | Not discussed | ‘The wording of the report should take into account the expected level of knowledge and expertise of the referrer’ | Not discussed |
Terminology—patients | ‘…bear in mind that a consumer may also read the report’ | ‘Patients now have access to medical correspondence about them... This should be borne in mind in the wording and style of the report’ | Not discussed | Not discussed | Not discussed | Not discussed |
Accuracy | ‘Relevant imaging findings should be characterised as specifically as possible’ | ‘….[the reporter] should be aware of the likely accuracy of the examination in that particular patient related to the published accuracy of the technique and its applicability to this particular examination…..’ | ‘The report should use appropriate anatomic, pathologic, and radiologic terminology to describe the findings’ | ‘Use precise anatomical, radiological and pathological terminology to describe the findings accurately’ | ‘[The findings] section should include a targeted, systematic and comprehensive description of all abnormalities….the description should be specific…’ | ‘It is …vital that the information contained within this record is accurate…’ |
‘Actionable reporting’ | ‘Specific clinical questions asked by the referrer must be addressed….’ | ‘A radiology report should be actionable and prompt appropriate care for the patient’ | ‘A specific diagnosis should be given when possible….a differential diagnosis should be rendered when appropriate…’ | ‘Give a precise diagnosis whenever possible… give a differential diagnosis when appropriate’ | ‘The report may give suggestions for further action to be taken….these suggestions should be carefully considered…’ | [The responsibility of the radiologist is to] ‘…clearly document advice on further management or action, where appropriate’ |
Confidence and certainty | ‘[The report should] avoid vague modifiers such as “might be consistent with” and “possibly represents”’ | ‘The level of certainty or doubt surrounding an imaging diagnosis should be clearly indicated in the report’ | Not discussed | ‘Descriptive reporting that offers no opinion, or guidance for the resolution of the clinical question should generally be avoided’ | Not discussed | Not discussed |
Clarity | ‘[The report should] use short sentences in preference to long sentences in prose reports and in the free text fields of itemised reports’ | ‘The written report should be clear, and written in a way appropriate to the referrer's expected level of familiarity with the imaging abnormalities detected…..’ | ‘Use of abbreviations or acronyms should be limited to avoid ambiguity’ | ‘The report should be clear and concise’ | ‘Observations should be as precise as possible, avoiding loose terms…’ | [The responsibility of the radiologist is to] ‘…ensure reports are …clear and precise’ |
Readability | ‘Clinical radiologists should review, edit and sign/authorise their own reports….to improve accuracy, clarity, readability, succinctness and logical order or examination findings, and their interpretation’ | Not discussed | Not discussed | Not discussed | ‘Long descriptions of limited use to the referrer should be avoided’ | Not discussed |