The radiology report is the main channel between the radiologist and the referring clinician, and decisions about the patient rest on it. The European Society of Radiology's good practice guidance on reporting stresses clarity, structure and a conclusion that answers the clinical question. This post summarises the structure of a good report, how to write findings and the mistakes that come up most often.
The parts of a report
Headings differ between departments, but a good report contains these parts:
- 1Clinical information and indication: the question the examination should answer. The impression must answer it.
- 2Technique: type of examination, contrast and any limitations (motion artefact, missing sequences).
- 3Comparison: date of the prior study and the change, or why no comparison was made.
- 4Findings: systematic, organ by organ, including relevant normal findings.
- 5Impression (conclusion): the interpretation of the findings, most important first, with a recommendation if needed.
How to write findings
- Be systematic: following the same order every time reduces the risk of missing an organ. That is why templates help.
- Location, size, characteristics: side, segment or lobe, at least two dimensions and imaging features.
- State pertinent negatives: what is *not* there is information too: "No acute haemorrhage."
- Use consistent terms: do not call the same structure by different names in findings and impression.
- Express uncertainty deliberately: reserve "possible" or "cannot be excluded" for genuinely uncertain cases.
Liver lesion, maybe a cyst.
A 15 x 12 mm well-defined, non-enhancing lesion of fluid density in liver segment 7, consistent with a simple cyst.
Why the impression matters most
Many clinicians read the impression first. It is therefore not a repetition of the findings but their interpretation:
- Answer the clinical question directly.
- Put the most important finding first.
- Give a clear recommendation where needed: further imaging, follow-up interval, clinical correlation.
- Leave no contradiction between findings and impression; nothing should appear in the impression that is not in the findings.
The most common mistakes
- Laterality errors: left/right mix-ups are among the most dangerous, especially with fast dictation and copy-paste.
- Leftover normal sentence from the template: a finding was added but the "normal" sentence for the same organ stayed, so the report contradicts itself.
- Size and unit errors: mm/cm confusion, a missing dimension.
- Forgotten comparison: a prior study exists but the change is not mentioned.
- Speech recognition errors: similar-sounding words swapped, unnoticed when the report is signed without reading.
Raporio prevents the leftover normal sentence: when you dictate a finding, it replaces the normal sentence for that organ instead of adding next to it, and the changed sentences are highlighted.
Structured reporting and templates
Structured reporting means using the same headings and order for every examination. It makes reports easier to read for clinicians and lowers the risk of missed findings for radiologists. Using your own normal reports as templates is the most practical way to get there.
In voice reporting the template matters even more: Raporio puts your finding into the right sentence of the template, while the normal sentences stay standard.
Frequently asked questions
What sections should a radiology report have?
Clinical information and indication, technique, comparison, findings and impression. The impression should answer the clinical question.
Should normal findings be reported?
Yes, especially pertinent negatives related to the clinical question; they are information for the clinician.
Should the impression repeat the findings?
No. It interprets them, puts the most important finding first and adds a recommendation where needed.
Try it with your own template
Say your findings and Raporio fills in your template. Nothing to install, it runs in the browser.
