Abstract
Objective:
To improve communication between attending physicians and radiologists by defining which information should be included in radiology reports and which reporting format is preferred by requesting physicians at a university hospital.
Materials and Methods:
Respondents were asked to choose among reports with different formats and levels of detail, related to three hypothetical cases, and questioned as to which characteristics commonly found in radiology reports are appropriate for inclusion. To assign the absolute order of preference of the different reports, the Kemeny-Young method was used.
Results:
Ninety-nine physicians completed the questionnaires (40.4% were resident physicians; 31.3% were preceptors of residency programs; and 28.3% were professors of medicine). For ultrasound with normal findings, ultrasound showing alterations, and computed tomography, respectively, 54%, 59%, and 53% of the respondents chose structured reports with an impression or comment. According to the respondents, the characteristics that should be included in the radiology report are the quality of the image, details of the clinical presentation, diagnostic impression, examination technique, and information about contrast administration, selected by 92%, 91%, 89%, 72%, and 68%, respectively. Other characteristics that were considered important were recommendations on follow-up and additional radiological or non-radiological investigation.
Conclusion:
Requesting physicians apparently prefer structured reports with a radiologist impression or comment. Information such as the quality of the examination, the contrast agent used, and suggestions regarding follow-up and additional investigation are valued.
Keywords:
Radiology information systems; Medical records; Referral and consultation; Tomography, X-ray computed; Ultrasonography
