A final radiology report is prepared at the end of a radiological scan and it encompasses the conclusion of the scan. It consists of the patient data, imaging findings and conclusions, and recommendations, if required. This is an electronically signed document which not just communicates the imaging results, but also serves as an important administrative document in the patient’s medical records.
The final radiology report is generally prepared by a licensed radiologist, with proper credentials. Other professionals such as radiology resident/ fellows or radiology technicians may aid in the preparation of a final report. However, the final radiology report can be signed only by a licensed radiologist. Apart from general radiologists, subspecialty radiologists can also sign the final radiology report. Some examples of the subspecialty radiologists are listed below:
Neuroradiologist
Musculoskeletal Radiologist
Body Imaging Radiologist
Pediatric Radiologist
Cardiothoracic Radiologist
Breast Imaging Radiologist
Interventional Radiologist (for procedure-related imaging)
Some of the imaging modalities are listed below:
Computed Tomography (CT)
Magnetic Resonance Imaging (MRI)
X-ray (Radiography)
Fluoroscopy
Mammography
Digital Breast Tomosynthesis (DBT)
Diagnostic Ultrasound
Doppler Ultrasound
Contrast-Enhanced Ultrasound (CEUS)
PET
SPECT
PET-CT
PET-MRI
Bone scans
Thyroid scans
Image-guided biopsies
Drainage procedures
Angiographic studies
Ablation and embolization procedures
A complete final radiology report must contain the following components:
Patient data:
This section includes the basic data of the patient such as name, age, sex, case number, etc. This information is used for the identification of the patient for administrative purposes.
Clinical History:
The final radiology report must explain the clinical history i.e., presented symptoms, past medical or surgical history, allergies, and the clinical question to be answered.
Imaging Technique:
There must be detailed information about the selected imaging modality, imaging technique, anatomical region that was examined, patient position, etc. must be explained in the report.
Radiological Findings:
This is the key section of the final radiology report. It consists of observations in the images. It also contains the description of the abnormalities in detail.
Final Conclusion:
By correlating the clinical data and the findings from the imaging test, the final conclusion of the radiological examination must be presented in this section.
Recommendations:
This section outlines the future recommendations, direction of the treatment, etc. If necessary, it may also contain suggestions for a re-examination or an alternate test.
Listed below is the step-by-step process of the generation of the final radiology report:
The radiological examination is performed at the hospital by a technologist to obtain the image.
After the images are generated, these are sent to Statim Healthcare for analysis.
At Statim Healthcare, a radiologist is allocated the case.
By combining the patient data with image findings, the radiologist puts forth a clinical diagnosis.
They then prepare a final radiological report with all the details as described above.
The report is then electronically signed and sent to the hospital using an RACS/PICS or a secure email delivery system.
The following imaging modalities are included in the final radiology reporting:
Plain Radiography (X-ray)
X-ray radiography utilizes ionizing radiation, which facilitates the visualization of the internal structure. X-rays are excellent in observing hard tissues like bones; however, they are not very effective for soft tissue evaluation. In the 2D images that are obtained, radiologists can easily observe physical deformities. X-rays can be divided into further subcategories such as chest X-rays (PA, AP, lateral), skeletal radiographs (fracture series, spine, joints), abdominal radiographs (erect and supine), pediatric skeletal surveys, and portable ICU radiographs. X-rays are widely preferred, as they are rapid and have a simple imaging procedure.
Ultrasound
Ultrasounds consist of directing high-frequency sonic waves to the area under evaluation. The waves reflected by the anatomical structures are detected and converted into grayscale images. Each tissue reflects back a unique frequency of sound waves, which allows for the differentiation between these tissues. Ultrasound imaging is used in the assessment of the organ size, texture, blood flow, fetal parameters, etc. There are several types of ultrasound performed, such as abdomen and pelvis ultrasound, obstetric and gynecologic ultrasound, Doppler ultrasound (vascular, portal, renal, DVT), small parts ultrasound (thyroid, breast, scrotum), pediatric ultrasound, and point-of-care ultrasound (POCUS) with confirmation.
Computed Tomography (CT)
Similar to an x-ray, a CT scan consists of using ionizing radiation to visualize the anatomy. Firstly, the ionizing radiation is used to produce thin slices of 2D images from multiple angles of the organ/supporting structures. The images are then reconstructed using a computerized system into a high-quality 3D image. CT is a rapid, efficient radiological technique that allows the observation of the anatomy from multiple planes. Some of the subcategories of CT imaging are CT brain (stroke, trauma, hemorrhage), CT chest (lung and mediastinum), CT abdomen and pelvis, CT angiography, trauma CT (pan-scan), and oncology staging CT.
A final radiology report is the complete document encompassing the findings observed in a radiological examination. A final radiology report is not just used to communicate the results of diagnostic imaging but also serves as official documentation in the patient information. It is an official document that can only be issued by a credible and licensed radiologist.
At Statim Healthcare, we offer services by qualified radiologists for the medical review of the diagnostic images and final report formation. These facilities help medical care unites provide more efficient services to the patients.