The Journal of National Accreditation Board for Hospitals & Healthcare Providers

LETTER TO EDITOR
Year
: 2014  |  Volume : 1  |  Issue : 1  |  Page : 17-

Seven C's of effective radiology reporting


Binit Sureka, Mahesh Kumar Mittal, Brij Bhushan Thukral 
 Department of Radiodiagnosis, VMMC and Safdarjung Hospital, New Delhi, India

Correspondence Address:
Binit Sureka
Department of Radiodiagnosis, VMMC and Safdarjung Hospital, New Delhi - 110 029
India




How to cite this article:
Sureka B, Mittal MK, Thukral BB. Seven C's of effective radiology reporting.J Nat Accred Board Hosp Healthcare Providers 2014;1:17-17


How to cite this URL:
Sureka B, Mittal MK, Thukral BB. Seven C's of effective radiology reporting. J Nat Accred Board Hosp Healthcare Providers [serial online] 2014 [cited 2020 Jul 16 ];1:17-17
Available from: http://www.nabh.ind.in/text.asp?2014/1/1/17/132920


Full Text

Sir,

The written radiological report is the most important means of communication between the radiologist and referring medical doctor. It is part of the patient's permanent health record and interprets the investigation in the clinical context. The appropriate construction, clarity and clinical focus of a radiological report are essential to high quality patient care. There is no universally agreed definition of a good radiology report and both radiologists and those who receive reports may hold differing views on the optimal style and content. Nevertheless, all radiologists wish to produce reports, which are accurate and also interpret the investigation for a particular patient in a way that assists with their further management.

In this context, I would like to highlight the Seven C's of effective radiology reporting. The Seven C's are - completeness, conciseness, consideration, concreteness, clarity, comparison and correctness. Completeness is to provide all necessary information and give some extra details when desirable. Conciseness means eliminating wordy expressions, including only relevant material and avoiding unnecessary repetition. Consideration is emphasizing positive, pleasant facts. Concreteness is using specific facts, figures and vivid, image-building words. Clarity is choosing precise, concrete, familiar words and constructing effective sentences and paragraphs. Comparison with previous imaging is a critical aspect in radiology reporting as it guides the treating clinicians regarding the treatment response or may even consider for revision of diagnosis. Correctness is using the right level of language and mentioning accurate location, size, density, extent, relevant positive and negative findings and relationship with other structures of the lesion described. One should avoid beginning a string of sentences with "There is…" or "There are…" Avoid redundant words, abbreviations, and phrases like "cannot be excluded." [1] Advice for relevant intervention, laboratory tests, and advanced imaging may be mentioned at the end of the report if required for the benefit of the patient. [2] If the examination reveals an abnormality, which requires urgent further evaluation or treatment, the radiologist has a duty of care to communicate this to the referring medical doctor. The date, time and person notified and the means of notification should be clearly stated in the report (ideally at the beginning or end of the report, rather than within the body of the report). [2]

In the current scenario of real time, tele and virtual radiology climate, where there is increasing plurality of provision of clinical services, it is important that the end-users of radiology reports are satisfied. Dissatisfaction could potentially cause clinicians to find alternative providers for their imaging needs. It is also important for us to know what clinicians want from the radiology reports as, ultimately, patient treatment is frequently determined by what is written in the report.

References

1Coakley FV, Liberman L, Panicek DM. Style guidelines for radiology reporting: A manner of speaking. AJR Am J Roentgenol 2003;180:327-8.
2European Society of Radiology (ESR). Good practice for radiological reporting. Guidelines from the European Society of Radiology (ESR). Insights Imaging 2011;2:93-6.