If you ever had any radiology exam, you may have read your radiology report. Or you´re a healthcare professional and you have one in your hand every now and then?

In this article I would like to talk about the radiology report in general. Let us discuss what this report is, what it contains, and what makes it special.

What Is a Radiology Report?

In brief: A radiology report is a written document created by a radiologist. The report is drafted after the radiologist has reviewed the acquired radiology images. It contains all information about the exam and provides a detailed description of the findings and meanings of the exam.

A radiologist’s report can be about any X-ray, ultrasound, MRI or CT study. There are also reports on interventional radiology procedures. In addition, these contain a detailed description of the performed intervention and its steps.

For many radiologists, writing reports is a major part of the everyday radiology life.

What Information Does a Radiology Report Contain?

Any person that reads the radiologists report should know who was examined and when, why and how the study was performed. In addition, after reading the person should know what was found in the study, how the findings were interpreted and what this means for the patient.

In the following section, I will briefly discuss the main components of such a report. Please be aware that this structure may differ depending on the country and/or type of hospital you are working in.

Typical Components of a Radiology Report

A typical radiology report includes the following components:

1. Patient Information: This section contains details about the patient, including their name, date of birth, identifier, and the date and time of the imaging study.
2. Referring Physician: Information about the physician who ordered the exam is included, including their name and contact information.
3. Indication and patient history: Information on the patient and why the study or procedure has been performed.
4. Study Information: Details about the type of imaging study performed, such as X-ray, CT, MRI, ultrasound, or other modalities. It also includes information about the specific body part or area that was imaged and whether contrast was applied.
5. Findings: This section contains the radiologist’s observations of the images or intervention. here you will read about abnormalities, lesions, fractures, or other relevant findings. In addition, measurements and other characteristics of these findings are put here.
6. Impression or Conclusion: In this section, the radiologist summarizes their findings and provides an overall assessment and interpretation of the findings of the study.
7. Recommendations: If additional imaging studies or procedures are needed, the radiologist may provide recommendations for follow-up care.

Radiology reports are crucial for patient care as they provide valuable information to the referring physician, who uses the report to make treatment decisions and develop a care plan for the patient. These reports are also a vital part of the patient’s medical record and can be referred to by other healthcare providers involved in the patient’s care.

What does Indication Mean on a Radiology Report?

In a radiology report, the term “Indication” refers to the reason or clinical justification for performing the radiological imaging study or procedure. It provides information about why the patient underwent the specific radiological exam. The information is typically provided by the referring physician who ordered the imaging study.

Ultimately, the radiologist decides whether this information or justification is enough to perform this study or procedure. The radiologist weighs the risks (e.g., radiation), alternatives (other modalities) and benefits (diagnosis) and takes responsibility for the conduct of the exam. If the indication is not sufficient, the patient cannot be examined and I as a radiologist often need to talk to the referring physician for additional information and further actions.

The Indication section of a radiology report serves several important purposes:

1. Clinical Context: It helps me, the radiologist to understand the clinical context in which the imaging study is being conducted. This context is essential for interpreting the images accurately and identifying relevant findings.
2. Guidance for Interpretation: The indication guides the radiologist in focusing their attention on specific areas or structures of interest. For example, if the indication mentions “right lower abdominal pain,” the radiologist will pay particular attention to the right lower abdomen when interpreting the images or conducting the procedure (e.g., ultrasound).
3. Relevance: It ensures that the imaging study is appropriate and necessary for the patient’s condition. Radiologists rely on the indication to confirm that the study aligns with the patient’s symptoms or medical history. In addition, this information is needed to decide wheter the exam should be conducted or if another modality may be suited better.

Examples of Indications for Radiological Exams

Common examples of indications in radiology reports include:

• “Evaluation of chronic back pain.”
• “Assessment of a suspected fracture in the left wrist.”
• “Follow-up of a known liver lesion.”
• “Evaluation of right lower abdominal pain of unknown etiology.”

The indication helps ensure that the radiologist’s interpretation is focused and relevant to the patient’s clinical presentation, and it assists in delivering accurate and clinically meaningful results to the referring physician.

The indication must be recorded in writing. This is especially true for the emerging field of teleradiology, where teleradiologists may work distant from the referring physician and the patient.

What does Impression Mean on a Radiology Report?

The term “Impression” refers to a critical (some say the most important) section of the report. In this section, we radiologists summarize and interpret the findings and provide an overall assessment of the patient’s condition based on the interpretation of the medical images.

It should offer a clear and clinically relevant summary of the imaging study’s results.

The Impression section is crucial for both referring physicians and other healthcare providers involved in the patient’s care, as it provides a clear and concise summary of the radiologist’s expert opinion. It helps guide further diagnostic and treatment decisions and facilitates communication among members of the healthcare team.

This Can Be Found in the Impression

In the Impression section of a radiology report, you can expect to find the following:

1. Summary of Findings: We radiologists will briefly recap the key findings from our review of the images (or procedure). This may include the presence of abnormalities, the description of any lesions or structural changes, the identification of fractures, or any other significant observations.
2. Diagnostic Assessment: We radiologists will provide our professional assessment of the patient’s condition based on the imaging findings. We may offer potential diagnoses and/or (a whole lot of) differential diagnoses, which are possible conditions that could also explain the observed abnormalities.
3. Recommendations: Depending on the findings and assessment, we may make recommendations for further evaluation or management. This could include suggesting additional imaging studies, consultations with other specialists, or specific treatment options.

Writing a short but concise impression is a difficult task that will be tought and learned during radiology residency.

What Does Non-Specific Mean in a Radiology Report?

The term “non-specific” is often found in our reports. We use it to describe findings or observations that do not display distinct or characteristic features that would allow a definitive diagnosis.

Non-specific findings in a radiology report indicate that the abnormalities or changes seen on the images are not unique to a specific disease or medical condition. Instead, they may be consistent with a range of possible causes or may not provide enough information to make a precise diagnosis based solely on the imaging study.

Here are a few key points to better understand why we would use the term “non-specific” in our radiology report:

1. Lack of Diagnostic Specificity: When I describe a finding as non-specific, it means that the imaging features are not distinctive enough to pinpoint a single diagnosis. It may suggest that further clinical evaluation or additional tests are needed to determine the underlying cause. In many cases non-specific (especially post-inflammatory or scarring changes) don’t require any further workup.
2. Possible Causes: Non-specific findings could be attributed to various factors, including inflammation, infection, trauma, or benign changes. Additional clinical information and follow-up tests may be necessary to narrow down the possibilities.
3. Clinical Correlation Required: To determine the significance of non-specific findings, the radiologist often recommends clinical correlation. This means the patient’s medical history, symptoms, and other diagnostic information should be considered when interpreting the report.
4. Follow-up Imaging: In some cases, non-specific findings may require follow-up imaging studies over time to monitor any changes or progression. This can help establish a more specific diagnosis or rule out certain conditions.

It’s important to note that while non-specific findings may not offer a clear diagnosis on their own, they still play a valuable role in the diagnostic process. They alert to the presence of abnormalities that may require further investigation and help guide the clinical evaluation and treatment plan.

Additionally, non-specific findings may become more specific with time and additional information, leading to a more precise diagnosis.

The Terminology is Used in Radiology Reports

In radiology, we sometimes use our own language. Although we use a similar terminology as other healthcare professionals, we may use it differently.

We radiologists have the complex task to put findings in a 2D or 3D-image or study into words. The reader (such as the referring physician) often does not look at the images but only relys on our report. This is why a variety of words, descriptions and paraphrasings may be used to describe a finding.

If the report has been written in free text, you may (depending on the author) also find almost poetic paraphrasing. Things can be shaped like a crescent moon or have a garland-like appearance. Also the size can be described as enormous or huge. As most institutes worldwide have their own “language”, you may find a large variety of different writing styles.

Tools to Write a Radiology Report

How do you actually write a radiology report? In fact, most radiologists (me included) do not actually write their reports. We rather dictate them into our speech recognition microphones. Afterwards or on the fly, a software transcribes the spoken text into written word.

With modern speech recognition software, this works very well as it adapts to the radiologists voice and the specific terms. However, often manual input is needed to correct and format the report before submitting it.

Structured Reporting in Radiology

Apart from free text reporting, structured reporting is increasingly used in radiology and many other fields.

Structured reporting in radiology means that there is a specific template for each type of imaging study. While reading the study, the radiologist does not dictate or write free text. Rather, she or he fills out the template or chooses from specific pre-defined options to generate the report.

That way, all reports using the same template will have a comparable structure. Using structured reporting can facilitate the process of writing a radiology report. Additionally, the information may be accessed easier by the reader (e.g., the referring physician) or software (e.g., for research purposes).

Example of a Radiology Report

As discussed earlier, radiologists reports can be very personal. They can and will look different depending on the clinical setting, the countries regulations and if structured reporting was used.

Below is a simple sample report:

Patient Information:

• Name: Pat Ient
• Date of Birth: January 15, 1975
• Sex: Male
• Medical Record Number: 123456789
• Referring Physician: Dr. Refer
• Date of Examination: September 27, 2023

Clinical History and Indication: The patient presents with persistent lower back pain and numbness in the left leg. Suspected lumbar spine pathology.

Procedure: Lumbar Spine MRI (sequences may differ between insitutes)

Findings: A multi-sequence MRI of the lumbar spine was performed and the following findings were observed:

1. Alignment: Normal alignment of the lumbar spine.
2. Vertebral Bodies: The vertebral bodies appear intact with no evidence of fractures or lytic lesions.
3. Disc Spaces: Disc spaces at the L2-L3, L3-L4, L4-L5, and L5-S1 levels are within normal limits.
4. Disc Desiccation: Mild desiccation is noted at the L4-L5 and L5-S1 levels, suggestive of early degenerative changes.
5. Herniated Discs: A broad-based central disc protrusion is identified at the L4-L5 level. This herniation is causing mild compression of the thecal sac without significant nerve root impingement.
6. Neural Foramina: The neural foramina at all levels appear patent without significant stenosis.
7. Spinal Cord: The spinal cord terminates at the L1-L2 level and appears unremarkable.
8. Soft Tissues: No evidence of abnormal soft tissue masses or collections.

Impression:

1. Mild disc desiccation at the L4-L5 and L5-S1 levels, suggestive of early degenerative changes.
2. Broad-based central disc protrusion at the L4-L5 level, causing mild compression of the thecal sac without significant nerve root impingement.

Recommendations: The findings are consistent with a disc herniation at the L4-L5 level, which may be contributing to the patient’s lower back pain and left leg numbness. Further clinical correlation is advised. Depending on the patient’s symptoms and response to conservative management, consideration may be given to physical therapy, epidural steroid injections, or surgical evaluation by a spine specialist.

Radiologist: Dr. Rad, MD, Board-Certified Radiologist, Date: September 27, 2023

Conclusion

The radiology report is a special piece of text. I hope you found some valuable infomation in this article.

Let me know if you have anything to add or if you have any feedback.

Happy reporting!