Specialist Registrars' Reporting Skills [QSI Ref: XR-508]
Descriptor
Specialist registrars’ reporting skills.
Background
The radiology report is the major path of communication between the radiologist and the referring clinician incorporating advice for further management/ imaging [5]. There is a close relationship between the structure of the report and its accuracy, so radiologists should strive to present information clearly and concisely in all circumstances [1,2].
There is often no change in an individual’s reporting style as a result of training beyond the first year [1]. Therefore, good practices are best introduced during the early years of training.
The Cycle
The standard:
- A locally agreed standard
- All reports for ultrasound, CT, MRI or contrast examinations by specialist registrars in their first three years of training should:
• Indicate the precise imaging examination
• State the drugs used (including intravenous contrast medium)
• Briefly describe the relevant findings
• Provide a differential diagnosis of the likely pathology
• Advise on further appropriate imaging
• End with a conclusion, impression or summary which includes only the significant diagnostic probabilities, excludes any repetition and addresses any question posed on the request form
Target:
100%
Assess local practice
Indicators:
Percentage of reports that achieved all 6 points above.
Data items to be collected:
- For each examination, complete an assessment proforma and record a coded identifier for the reporting specialist registrar [1-5]
- Keep the results anonymised
Suggested number:
10 randomly selected examinations carried out by each trainee in years 1–3 of training.
Suggestions for change if target not met
- Refresher course in reporting skills. Formal teaching of reporting skills during the local FRCR I course and further reinforcement during the FRCR II course [1-4]
- Encourage all trainers to develop (for themselves) a local reporting format that matches the standard
- The Head of Training should address the particular needs of those specialist registrars who continue to fall below the standard
Resources
- Review of reports, assessment proforma
- Radiologist (1 hour per specialist registrar)
References
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Hessel S J et al. The composition of the radiologic report. Invest Rad 1975;10:385–90.
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Sierra A E et al. Readability of the radiologic reports. Invest Rad 1992;27:236–9.
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Lafortune M et al. The radiological report. J. Can Assoc Rad 1982;33:255–66.
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Orrison W W et al. The language of certainty: proper terminology for the ending of the radiologic report. AJR 1985;145:1093–5.
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Royal College of Radiologists Standards for the Reporting and Interpretation of Imaging Investigations. Second edition, London: RCR, 2018. https://www.rcr.ac.uk/publication/standards-interpretation-and-reporting-imaging-investigations-second-edition
Editor’s comments
Where possible, particularly for the more experienced registrars, reports should be selected that have been issued solely by the registrar. If there is a second author, then reporting structure and content errors may have been corrected by the second, supervising author.
Submitted by
Taken from Clinical Audit in Radiology 100+ recipes RCR 1996, updated by K A Duncan & N Spence