Standardised reports may be a helpful starting point for reporting examinations. However, with practice and confidence, breaking away from the standard report is possible and, in most cases, desirable.
The standard report may help to remember review areas and in times of increasing litigation may be considered useful. However, the standard report may be wordy and overly complex for answering the question posed by the clinician.
Most reports have the following layout:
What the clinician wrote on the card - supplemented by any other important and pertinent information gainned from other sources (such as previous reports).
Helpful to give you and the clinician an idea of how sensitive the result is. A non-contrast abdomen looking for renal stones is less sensitive at looking at the bowel than a CT abdomen/pelvis with oral and IV contrast. Similarly a CT abdomen that stops at the iliac blade cannot assess the sigmoid and colon.
Inclusion of whether or not a comparison study is available and when it was from is useful here too.
CT chest, abdomen and pelvis with oral and IV contrast
Comparison CT: 14 August 2009.
Non-contrast CT head: no comparison CT available
Triple-phase pancreatic study
No previous CT available for comparison
The body of the report. findings of the case including relevant negative findings.
A summary of the findings. This may be a couple of short sentences or a bulleted list. Don't simply repeat what was described in the findings section. It is also pointless to write "findings as above" or words to that effect, as this adds nothing. A short and snappy conclusion lets the clinician know all the pertinent points and allows them to choose whether to read the whole report.
Title, name, job title and professional registration number of the reporter.
e.g. Dr Jon House, Consultant Radiologist, GMC 1234565