Original articleQuality of the Written Radiology Report: A Review of the Literature
Introduction
The written radiology report is the dominant method by which radiologists communicate their interpretations of imaging findings. The quality of the report therefore has a direct impact on the safety and appropriateness of decisions about treatment and further investigations. The written report also may be used in education or research, serve as a legal document, or provide billing information. Several clinical practice guidelines and a number of publications in the radiology literature have considered the style, content, timeliness, and clarity of the written radiology report and how it might be improved. The Royal Australian and New Zealand College of Radiologists, through the Quality Use of Diagnostic Imaging program, carried out a literature review guided by the question, “What are the important elements of a high-quality radiology written report?”
The aims of this literature review were to (1) identify the evidence relating the form and content of the written radiology report to objective or subjective measures of quality (such as clarity, utility, comprehensiveness, and the extent to which the report addresses the key question[s] posed in the clinical notes provided in the referral for imaging); (2) determine significant gaps in the evidence that could be filled by further research, such as a practitioner (provider or referrer) survey; and (3) use the information from the literature review and the subsequent survey to inform the development of guidance for curriculum development and evidence-based clinical practice guideline development regarding the radiology report by the Royal Australian and New Zealand College of Radiologists.
Section snippets
Identification of Professional Standards of Radiology Reports
The Web sites of the ACR, the Royal College of Radiologists, Royal Australian and New Zealand College of Radiologists, the European Society of Radiology, and the Canadian Association of Radiologists were searched for guidelines relating to reporting on March 23, 2009. Common issues addressed by these radiology reporting guidelines were identified, and recommendations of each were summarized.
Systematic Review of the Literature on Standards of Radiology Reports–Data Location and Selection
Two papers, by Sistrom et al [1] and Houssami et al [2], relating to the issue of quality in written
Results
No systematic reviews of this topic were identified.
Discussion
Existing guidelines about the written radiology report do not fully document their objectives, evidence appraisal, or development methodology and do not address implementation issues. Current and future guidelines should be integrated into radiology training programs and continuing professional development.
Published studies consist mainly of surveys or observational report audits and analyses. There is a major gap in published studies relating to testing of interventions to improve report
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Dr Pool was funded by the Quality Use of Diagnostic Imaging program from November 2008 until December 2009.