1/7/2024 0 Comments Normal chest x ray findings![]() ![]() Unfortunately it is not uncommon to find a new malignancy on a mammogram or chest radiograph which in retrospect was present and reported out by a colleague as "normal" "The lung fields are normal" becomes "normal lungs". "There is an area of linear atelectasis in the right lower lobe" should be - "Linear atelectasis right lower lobe." Short reports equate to haste and carelessness. However, long reports cost money to produce and read. Lawyers will argue that reports should be wordy as a defense against malpractice. Inadvertent vs unintentional - legally, inadvertent means careless. recommendations for further investigations.What would you conclude if you read this report? Put yourself in the referring physician's shoes. Avoid "if clinically indicated." Don't hedge. Juries do not understand poorlyĭon't be vague. Make the referring physician look good - A common phrase "fracture is poorly aligned" should be avoided. Lack of comparison is a common factor in the loss of a malpractice lawsuit.Ĭall Results forunexpected, life-threatening problems call the referring physician. Measure if possible or use qualifiers- mild, moderate, severe.Ĭompare, Compare, Compare. Normal except for cancer RLL is unacceptable. Clinicans have been asked what they want: "brief description of the radiographic findings." ![]() This is the format preferred by the referring clinician.īe brief. This reverse logic brings the most important information to the top where it is seen or heard first. The same problem is inherent in reading reports online, the referring clinician may have to scroll, or worse, page to the conclusion. Those listening to the report have to wait until the end to hear the conclusion. In the modern hospital environment it has disadvantages. The facts are weighed and a conclusion made. This is logical and follows the inductive method. The report reflects the attitude, perception and capability of the radiologist and serves as a legal document. The radiology report is the primary means of communication between the radiologist and the referring physician.
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