An X-ray report is the most important and widely used method of communication between the radiologist and the referring physician. The direct communication may be possible sometimes, but if one has to resort to it, it most likely means that the radiologist didn’t do his job properly. As you may see, learning how to write it is a crucial part of a radiologist’s job; and in order for you to better understand how it is done, we’ve prepared a set of basics of how to write a normal chest x ray report sample which you can refer to for guidelines.
1. Two Approaches
The details may be different depending on the type of X-ray you work on, but some underlying principles are universal and unchanging. There are two basic approaches to the structure of a normal chest report: the first and most popular format consists of discussion and impression. In discussion, you present your findings, describe and evaluate them. In impression, you draw conclusions based on the facts and present your diagnosis.
The less widely used format also consists of two parts: diagnosis and discussion. As you may see, the methods are reverses of each other, and both have their pros and cons. The first method allows for logical organization of material and well-backed conclusions, but forces the physician to read it in its entirety to get to the important part. The second one presents the most important information first and supporting facts later.
In the long run, it doesn’t matter which method you use as long as you follow certain principles the most important of them being brevity. Physicians don’t want to read long and complicated descriptions of your findings. They want as much information as possible in as few words as possible. If a clinician encounters a wordy description, his attention may waver, resulting in missed information. It concerns not only the overall length of the report and covering of insignificant details, but the way you choose words and construct sentences. Avoid unnecessary words and wordy sentence structures. Trim all the fat you can trim, leaving only really important data.
3. Important Findings First
Present the most important findings first, both in the report in general and in every particular sentence. For example, never write something like “Normal except for degenerative changes in the thoracic spine” – the clinician reading the report may notice normal and stop at that, considering that there is nothing more to it. X-ray reports are often read in tense atmosphere, and physicians are often pressed for time. Therefore, the less possibilities there are for mistakes in communication, the better.
Be as precise as possible. If something can be measured on your X-ray sample, do it. If it isn’t possible, at least provide qualifiers: severe, insignificant, noticeable.
In the long run, an X-ray report should be only a few very exact, curt sentences accompanying the X-ray per se. It may seem that they don’t require a lot of expertise to write – however, removing everything that is unnecessary and leaving only the crucial information requires a lot of skill.