iRADiX

The Art and Science of Reporting in Radiology: Part 6

How to conclude the report?

What do you call it?

Call it “Summary”, “Impression”, “Conclusion”, “Opinion”, or “Comment” (I call it “Summary” in this discussion), but avoid "Diagnosis", because diagnosis is more specific, and is a combination of clinical, radiological, biochemical, microbiological, and histopathological factors.

Summary is not mandatory.

Not all reports should have a summary. If the main report itself is short and precise, there is no need to repeat the same thing again in summary.

Avoid long descriptions for normal findings.

Example: "The kidneys appear normal" is enough, there is no need to say "Both kidneys appear normal in size and echotexture. The corticomedullary differentiation is maintained. The margins are smooth. There is no evidence of calculus or hydronephrosis".

Avoid unnecessary words.

Example: "The Kidneys appear normal" rather than "Both kidneys appear normal", or "The kidneys appear normal bilaterally"

Some things can wait. For some things the patient can come back. They can come back for a Pathology report as that takes time to process. They can come the next week for the Hormone assays report as the lab is setting up the tests only after they get a required number of samples collected together. They can come next time, as their surgeon is busy in a surgery. But when it comes to a Radiology report, they have either come from out of town, or are VIPs, or this is an urgent report and they just cannot wait.