Specialist Registrars' Reporting Skills [QSI Ref: XR-508]

Specialist registrars’ reporting skills.

The radiology report is the major path of communication between the radiologist and the referring clinician incorporating advice for further management/imaging [1]. There is a close relationship between the structure of the report and its accuracy, so radiologists should strive to present information clearly and concisely in all circumstances [2, 3].

It has been recognised as difficult for registrars to change their reporting style after the first year of training [2]. Therefore, good practices are best introduced during the early years of training.

The standard: 

- A locally agreed standard

- All reports for ultrasound, CT, MRI or contrast examinations by specialist registrars in their first three years of training should:

   • Indicate the precise imaging examination

   • State the drugs used (including intravenous contrast medium)

   • Briefly describe the relevant findings

   • Provide a differential diagnosis of the likely pathology

   • Advise on further appropriate imaging

   • End with a conclusion, impression or summary which includes only the significant diagnostic probabilities, excludes any repetition and addresses any question posed on the request form

Target: 

100%

Indicators: 

Percentage of reports that achieved all 6 points above.

Data items to be collected: 

- For each examination, complete an assessment proforma and record a coded identifier for the reporting specialist registrar [1-5]

- Keep the results anonymised

Suggested number: 

10 randomly selected examinations carried out by each trainee in years 1–3 of training.

(e.g. 2 XR, 2 US, 2 fluoro, 2 CT, 2 MRI)

• Refresher course in reporting skills. Formal teaching of reporting skills during the local FRCR I course and further reinforcement during the FRCR II course [2-5]
• Encourage all trainers to develop (for themselves) a local reporting format that matches the standard
• The College Tutor/Training Programme Director should address the specific needs of those specialist registrars who continue to fall below the standard

- Review of reports, assessment proforma

- Radiologist (1 hour per specialist registrar)

1. Royal College of Radiologists Standards for interpretation and reporting of imaging investigations. Second edition, London: RCR, 2018. https://www.rcr.ac.uk/our-services/all-our-publications/clinical-radiology-publications/standards-for-interpretation-and-reporting-of-imaging-investigations-second-edition/

2. Hessel S J et al. The composition of the radiologic report. Invest Rad 1975;10:385–90.

3. Sierra A E et al. Readability of the radiologic reports. Invest Rad 1992;27:236–9.

4. Lafortune M et al. The radiological report. J. Can Assoc Rad 1982;33:255–66.

5. Orrison W W et al. The language of certainty: proper terminology for the ending of the radiologic report. AJR 1985;145:1093–5.

Taken from Clinical Audit in Radiology 100+ recipes RCR 1996, updated by K A Duncan & N Spence, J Mak 2024.