Enhancing Report Communication & Highlighting Key Findings

Visual Impact: Add a Key Image Here

Space for a relevant image that highlights a critical finding.

*Providing one or two relevant images directly within the report can significantly enhance clarity and impact, especially for complex or critical findings.*

Effective communication in medical reports is crucial for patient management and inter-physician collaboration. Here are key strategies to improve your reports and ensure important findings are clearly conveyed:

• Understand Physician Expectations: If referral notes are unclear, communicate directly with the physician to understand their specific questions and expectations from the scan.
• Structure Complex Findings: For complicated findings (e.g., pancreatic cancer), divide the report body into logical parts. One part can detail the primary abnormality (tumor, extension, vascular anatomy), and the second can cover other findings.
• Include Relevant Images: Embed one or two representative images directly in the report to visually support key findings. This helps physicians quickly grasp the critical information without sifting through many films.
• Highlight Critical Findings: For self-explanatory critical findings (e.g., obstructing calculus), the image itself can convey the message powerfully, serving as a safeguard against textual errors.
• Concise Impression: The impression section should be point-wise, addressing the physician's specific question first. Include other relevant incidental findings that may require future attention (e.g., vertebral compression fracture).
• Direct Communication: Call and discuss important findings that are difficult to articulate in writing. Remember, physicians often have limited time and prefer concise information over lengthy essays.
• Simplify Radiology Lexicon: Avoid overly technical radiology jargon, as not all physicians are specialists or updated with every term. Aim for clarity and simplicity.
• Structured Reporting for Complex Cases: For studies like "fistula studies," report each fistula separately, detailing its ramifications, openings, and associated abscesses. Consider including key images or even simple drawings.
• Mention Limitations: Always state any limitations of the scan, such as patient motion, artifacts from implants, or reduced resolution due to patient obesity.
• Provide Final Diagnosis/Differentials: Whenever possible, offer a final diagnosis (e.g., classical hemangioma). If uncertain, provide possible differentials (e.g., FNH vs. Adenoma).
• Avoid Long Sentences: Break down multiple findings in the same region into separate, shorter sentences for better readability.
• Organize by "Stations": Consider describing the body of the report by anatomical "stations" or regions (e.g., Adrenal and urinary system in one paragraph, Hepatobiliary and pancreas in another).
• Practice "Satisfaction of Search" Avoidance: Develop a defined, systematic pattern for reviewing every scan, regardless of the initial clinical question. This ensures all areas are thoroughly examined, preventing missed findings due to focusing only on the suspected abnormality.
• Club Normal Organs: Consolidate descriptions of normal organs into one or two concise sentences (e.g., "The liver, spleen, pancreas, gallbladder, intra and extra hepatic bile ducts are unremarkable.").
• Comparison with Previous Scans: Always include comparisons with prior studies, especially critical in oncology follow-ups.
• Mention Case Discussions: At the end of the report, you can mention if the case was discussed with a colleague (e.g., "Case discussed with Dr. XYZ"), reminding the physician to read the full body of the report.
• Acknowledge Peer Opinion: With their consent, you can mention the name of a colleague whose opinion you obtained.
• Admit Uncertainty: If you cannot explain the significance of a finding, it's professional to state that you don't know and request more time to investigate.
• Use Appropriate Terminology: Instead of "advised" or "recommended," use softer terms like "suggested" or "if of concern."
• Clinical Correlation vs. Specific Inputs: Based on evidence-based practice, you can provide specific suggestions. However, be mindful that some referring physicians prefer not to be told what to do.

Case Example: Highly Vascular Polyp

A highly vascular polyp in the cervix, arising from the endometrium, posed a significant risk of torrential bleeding upon simple probing. The image was striking and conveyed the impact immediately. Concurrent communication with the gynecologist was crucial, leading to a revised plan: either embolization before polypectomy or planning a hysterectomy. This highlights how direct communication, combined with a powerful visual, can drastically alter patient management.

Impression Example: Ovarian Carcinoma Follow-up

Impression:

- Prominent vaginal cuff on the left side with heterogeneous enhancement as
   described.
- Subtle nodular thickening is seen in the fat deep to the right abdominal wall.
   The significance is undetermined. Clinical correlation with CA-125,
   and short follow-up is suggested.

- No evidence of ascites or significant lymphadenopathy.
- Hepatomegaly and splenomegaly with underlying changes early changes of
   portal hypertension. Liver parenchymal disease to be ruled out.
   Further gastroenterology consultation is suggested.
            

Prepared by: Dr. Sharad Maheshwari

Published: 27.9.2022

Updated: 28.12.2022