Radiology reports are a type
of clinical note that tends to have clear and consistent
formatting and sections. Most radiology reports will
describe the type of exam. For example, was it a CT exam or an MRI? There will also be details
on where the images were taken like abdomen versus left wrist. You may also see important details about the exam such as if contrasts was
used during the imaging study. Then there is typically a section
describing the clinical history. This usually comes from
the radiology order placed by the provider outlining
the pertinent medical history and reason for the imagery and study. Next, we will imagine
of whether there were any other imaging studies of the same
area that were used for comparison. Sometimes the studies
maybe the same type. For example, a CT scan compared
to a CT scan from a year ago, or it may be a completely
different imaging type. This is common when
the patient has a finding on a lower resolution imaging
type like x-rays or ultrasounds and is now getting a more detailed imaging study
completed like a CT or MRI. The technique section then describes how the imaging study
was actually performed. This is a much more in-depth description than that listed in the type of exam. In most cases, this isn't clinically meaningful except to other radiologists. The next section is
the findings section which outlines all of the observations made by
the radiologist from the imaging study. At a minimum, this describes
it the area was normal, abnormal, or possibly abnormal. This section contains
the most objective data about the imaging results in the report. Finally, imaging reports and in the impression section
where the radiologists combines the patient's
clinical history with the imaging findings to
provide a diagnosis, as well as, recommendations for
additional studies that may be necessary.