Stop Free-Dictating

There are many institutions/practices with well-defined “normal” templates for all types studies, which help provide a reasonable approximation of a house style. A clinician (or the next radiologist) has a reasonable chance of knowing where to find the information in the report. The reader can see something in the impression and quickly find the longer description in the body of the report for more information.

Templates can be brief skeletal outlines or include more thorough components containing pertinent negative verbiage. A section for the Kidneys could say “Normal” or it could say, “No parenchymal lesions. No calculi. No hydronephrosis.” Some groups have diagnosis-specific templates that build off a generic foundation to better address specific concerns like renal mass characterization or appendicitis.

Either way, some form of templating is critical to creating a readable report. After all, radiology for better or worse is a field where the report is the primary product, and creating reports that are concise, organized, and readable should be a goal.

Some institutions and practices do not have these baseline templates. There are (often but not always older) attendings who seem to not only practice but respect the freewheeling old school transcriptionist style of reporting. A resident who doesn’t “need” a template is to be prized and congratulated.

This isn’t 100% wrong either. It’s a useful ability in the sense that it’s important to be able to summarize findings in cohesive English. It’s largely the same skill as the casemanship skills used during hot-seat conferences that the recent Core exam generation of residents have largely lost, and so I can appreciate this perspective. However, at least from a reporting perspective, this is wrong in the 21st century.

 

The purpose of the radiology report

The first attending I ever worked in radiology was a neuroradiologist who posed a semi-rhetorical question on my first day. He used to ask:

What is the purpose of the radiology report?

The answer, he argued, was to create the right frame of mind in the reader.

I think this view is exactly right.

Defined in a narrow sense, this means that the reader should come away with the impression that you intend for them to have. If something is bad and scary, that should be clear. If something is of no consequence, that should also be clear. Items in the impression are there because we want those impressed on the minds of our readers, not just because we saw them.

With increasing patient access to radiology reports, we now have a second audience. While doing away with all medical and radiological jargon is probably misguided and unnecessary, we need to at least be cognizant of how our reports might read to a layperson (or non-specialist, for that matter). If we can be more clear and more direct, we have a greater chance of communicating effectively to all involved parties.

Templates make reports more organized, scannable, and readable. Not even debatable.

But while the primary intent of “frame of mind”-creation may relate to the significant radiological findings, it’s also about creating the right frame of mind about you, the radiologist. Thorough, thoughtful, organized, conscientious? Or rushed, disorganized, careless, apathetic?

There may be some perks of blinding readers with science and drowning readers in long-winded descriptions of even benign and irrelevant incidental findings. At least you won’t look lazy! But for the less verbose among us, we can show we care by creating reports that reflect our systematic approach and clear writing style. Templating is critical to creating digestible reports.

Lastly, as quality metrics rise in importance and resource utilization re-enters the arena as a responsibility of the radiologist, we also need our reports to be readable and indexable by computers. The easier our reports are to parse, the easier we can extract meaningful data about our findings, link these up with patient data from the EMR, and draw high-powered conclusions about patient impact, outcomes, and (of special importance to me) the utility of certain exams in specific clinical contexts.

 

Dictation software is a tool, not a recorder

If you’re a resident somewhere and your institution doesn’t have power normals to frame-out your reports, make some. If you find yourself saying the exact same things over and over again every single day, then you’re doing it wrong. It should either part of the template or an auto-text macro. If nothing else, it will reduce your rate of transcription errors.

No one needs to reinvent the wheel on every case!

Leave a Comment.