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 many cases, desirable. On the other hand, in some instances, standardised reports facilitate the creation of automated systems related to the reports, including those that feed artificial intelligence applications. Many institutions use templates to encourage standardised reporting.
The standard report may help to remember review areas and may be considered useful in times of increasing litigation. However, it may be wordy and overly complex to answer the clinician's question.
Standard report
Most reports have the following layout:
Clinical details
What the clinician wrote on the referral can be supplemented by important and pertinent information from other sources (e.g., further history from the patient, previous reports, pathology reports).
Technique
It can help give you and the clinician an idea of how sensitive the result is. A non-contrast CT abdomen looking for renal stones is less sensitive to 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 colon.
Inclusion of whether or not a comparison study is available and when it was from is useful here too (or is sometimes included as separate subheading).
Examples
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
Findings
The body of the report. Findings of the case including relevant negative findings.
Summary
A summary of the findings. This may be a couple of short sentences or a numbered or bulleted list. Do not 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.
Reporter's details
Title, name, job title +/- professional registration number of the reporter.
e.g. Dr Jon House, Consultant Radiologist, GMC 1234565
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