How to Create a Great Radiology Report
How to Create a Great Radiology Report
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DOI：
10.1148/rg.2020200020
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发表时间：
2020-10-01
期刊：
影响因子：
5.5
通讯作者：
Kanne, Jeffrey P.
中科院分区：
文献类型：
--
作者：
Hartung, Michael P.;Bickle, Ian C.;Kanne, Jeffrey P.
放射学报告代表了放射科医生对患者病情的最高综合水平和洞察力的总和。它是放射科医生为帮助指导患者护理而产生的最重要的产品。尽管清晰有效的放射学报告的重要性不言而喻，但放射科医生在培训期间通常很少或根本没有接受正式的报告教育。相反，它是通过偶尔的纠正和模仿其他放射科医生的报告，以一种零碎的、经常是间接的方式学习的。放射学报告的受众远远超出了订购供应商，包括患者及其家属，医疗支持人员，专科供应商，其他放射科医生和研究兴趣。创建一个满足这个多样化群体需求的报告是一个艰巨的目标，如果不是堂吉诃德式的野心。然而，报告影像学发现、印象和建议有一些关键原则，这些原则可作为指导，并促进对如何理解报告的仔细考虑。调查结果部分应强调简短、信息丰富和事实性的观察，同时避免不适当的解释、过度使用感知术语和冗余。印象是对诊断、鉴别诊断和治疗建议的结果意义的深思熟虑的综合。创建一个清晰和有影响力的印象允许放射科医生提供最高水平的临床护理和指导，但需要时间和精力，而不仅仅是简单地重述结果。印象应该使用可理解、可记忆和可操作的语言。报告技能需要持续关注，必须适应不断变化的实践模式和沟通方式。(C)RSNA，2020年
The radiology report represents the sum of a radiologist's highest level of synthesis and insight into a patient's condition. It is the most important product that radiologists generate to help direct patient care. Despite the self-evident importance of clear and effective radiology reporting, radiologists usually receive little or no formal reporting education during training. Instead, it is learned in a piecemeal and often indirect fashion through occasional correction and imitating the reports of other radiologists. The audience of the radiology report extends far beyond the ordering provider and includes patients and their families, medical support staff, subspecialty providers, other radiologists, and research interests. Creating a report that fulfills the needs of this diverse group is a formidable if not quixotic ambition. However, there are certain key principles to reporting the imaging findings, impression, and recommendations that serve as a guide and promote careful consideration about how reports are understood. The findings section should emphasize short, informative, and factual observations while avoiding inappropriate interpretation, excessive use of terms of perception, and redundancy. The impression is the thoughtful synthesis of the meaning of the findings leading to a diagnosis, a differential diagnosis, and management recommendations. Creating a clear and impactful impression allows radiologists to provide the highest level of clinical care and direction but takes time and effort beyond simply restating the findings. The impression should use language that is understandable, memorable, and actionable. Reporting skills require ongoing attention and must adapt to the evolving practice patterns and communication styles in medicine. (C) RSNA, 2020