1. Step Up to Bat and Practice Dictating
Complex Cases: A Resident's Guide to
Effective Reporting
Mark D. Mamlouk, MD1
Eric vanSonnenberg, MD2,3
1University
of California, Irvine
2Kern/UCLA Medical Center
3Arizona State University

2. INTRODUCTION
Radiology residencies provide little formal training in image
reporting. Studies have shown that residencies designate at
most one hour per year on dictation education. There is no
standard model or guide for residents to adhere to during their
training.
Clinicians have expressed dissatisfaction with radiology
reports—41% of 432 clinical specialists feel that the radiology
report is not valuable (Bosmans Radiology 2011). Clinicians
believe our reports are too vague.
Our purpose is to highlight important and effective reporting
guidelines and strategies using interesting image-based cases
that encompass all branches of radiology, thereby increasing
resident education and clinician satisfaction.

3. EFFECTIVE REPORTING
Clinical History: 47 F with Adequate,
new onset memory loss billable history
Findings:
There is a 5 mm focus of
Detailed, yet
reduced diffusion in the concise findings
left hippocampus.
Impression:
Findings compatible with Answers
transient global amnesia. clinical question
• Effective reports are straightforward
• Report descriptions should be complete, but with a parsimony of
words
• Findings & Impression contain relevant points and are not
redundant
• Findings are for the radiologists and the Impression is for the
clinicians
• Reports are clinically oriented, i.e. attempt to make a clinical
diagnosis rather than simply describing findings
• Include prior comparisons, technique, contrast name and amount,
radiation dose

4. FINDINGS IN THE REPORT
PREFERRED DICTATION
SUBOPTIMAL DICTATION
• Findings should be organized Clinical History: 52 F with
Clinical History: 52 F with hematuria
• Use paragraphs hematuria
Findings:
• Include pertinent positives & The lung bases are well aerated. The
Findings: Paragraphs
The lung bases… make easier to
negatives liver and spleen are normal. There is read
compression of the left renal vein by the
• Be complete, even if aorta and SMA along with the presence
There is compression of the left
renal vein by the aorta and SMA
normal—50% of polled of a large left gonadal vein. There are
along with the presence of a large
left renal and pelvic varices. The adrenal
clinicians believe if an glands, pancreas, and right kidney are
left gonadal vein. There are left
organ/structure is not renal and pelvic varices.
normal. The bowel is nondilated and
mentioned, the radiologist did there is no bowel obstruction. The Grouping
The liver, spleen, adrenal
osseous structures are normal. related findings
not closely evaluate it glands…are normal. more logical
Impression: Nutcracker syndrome
Impression: Nutcracker syndrome

5. IMPRESSION IN THE REPORT
• Single most important component of the radiology report
• Should be concise, unambiguous, and not reiterate the findings
• Should be separate from findings--94% of 703 polled clinicians believe that a radiology
report greater than a few lines should have a separate conclusion (Bosmans Radiology 2011)
• Should be numbered in decreasing importance; if a sole impression, don’t number
• Should answer the clinical question!
Findings:
There is a nonenhancing mass extending from the
right gonadal vein to the IVC to the right atrium.
There is thrombus within the hepatic veins. The
uterus is large and lobular with internal fibroids.
Impression:
Intravenous leiomyomatosis and secondary
Budd-Chiari syndrome
Findings:
There are numerous perivascular spaces bilaterally
that follow CSF signal. The sella is J-shaped.
Impression:
Findings suggestive of a mucopolysaccharidosis
(Hurler disease, in this case)

6. ANSWER CLINICAL QUESTION
SUBOPTIMAL
PREFERRED DICTATION
IMPRESSION
Clinical History:
Impression:
8 m/o M with lower GI
bleeding—evaluate for
High tracer uptake in the
Meckel diverticulum.
RLQ compatible with a
Meckel diverticulum.
Impression:
High tracer uptake in RLQ.
• Although obvious, answering the An easy, everyday case to
clinical question is not always evaluate PICC placement SUBOPTIMAL PREFERRED DICTATION
IMPRESSION
done(these two cases) Findings:
Clinical history: There is a new right-sided
• Should be the first Impression Evaluate PICC PICC with the tip projecting
placement over the mid SVC. The
• Succinct and straightforward lungs are well aerated. The
Findings/Impression: cardiomediastinal
• Guides radiologist to commit to a There is a new PICC silhouette is not large.
diagnosis identified. The lungs
are clear. The Impression:
• Will increase clinician’s satisfaction cardiomediastinal
silhouette is stable.
Satisfactory PICC position.

7. HANDLING NORMAL VARIANTS
Clinical History:
37 F preoperative for pituitary tumor resection
Impression:
1. Pituitary tumor unchanged (not shown).
2. Persistent trigeminal artery, a normal variant,
that should be considered in surgical planning.
• Significant normal variants should be mentioned in the Impression
• Knowledge on when a normal variant can affect management is important
• Trivial normal variants can be discussed solely in the Findings
• If there is a rare normal variant that the clinician may not be aware of, mention “this is a
normal variant” to not confuse with pathology

8. LIMIT COLLOQUIALISMS
SUBOPTIMAL IMPRESSION PREFERRED DICTATION
Clinical history: 2 y/o M with Impression:
difficulty stooling
Constellation of findings
Findings: indicative of Currarino triad.
There is a presacral cystic mass
contiguous with the thecal sac.
There is hypoplasia of the “Clinically correlate”
sacrum and coccyx. A • Commonly used radiologist
significant amount of stool is phrase
seen in the rectum secondary
• Does not add value to report
to anal stenosis (not shown).
• Clinicians satirize this
Impression: expression
Presacral cystic mass, skeletal • Does NOT save you from the
anomalies, constipation.
court room
Clinically correlate.
SUBOPTIMAL IMPRESSION
Findings:
There is a dissection flap extending from the ascending aorta across
the aortic root and into the subvalvular left ventricular outflow tract
(LVOT). There is a subtle dissection in the left main coronary artery
ostium.
Impression:
Aortic dissection extending to the LVOT and left main coronary artery.
If clinically indicated, MRI is recommended.

9. LIMIT COLLOQUIALISMS (Cont.)
“If clinically indicated”
• Before reporting this vague phrase, ask yourself what it means to you if you
were the clinician?
• Clinicians may sometimes feel obligated to get additional imaging despite “if
clinically indicated”
• Think about the implications of this statement before mentioning it (delaying
care [as in this case], clinician’s responsibility, cost, radiation, patient anxiety &
stress)
• While there are cases this statement may be said, consider clinical context &
determine if relevant first
• If radiologists want to be accepted as clinical colleagues, we must take
ownership--this is our patient too! Do not rest everything on the clinician.

10. CLINICAL HISTORY
PREFERRED DICTATION
• The lack of a good clinical SUBOPTIMAL
history is the radiologist’s DICTATION Clinical History: 3 y/o M
with ALL s/p bone marrow
bane Clinical history: rule transplant with graft-versus-
• In the age of EMRs out bowel obstruction host disease (GVHD) and
abd pain
though, a pertinent history Findings:
is only a mouse click away There are fluid-filled Findings:
loops of small bowel There are fluid-filled loops
from the radiologist that enhance, but are of small bowel with thin
• Without an adequate not obstructed. central enhancement in the
expected location of the
history, you may not get Impression: mucosa.
paid for the study...and 1. No bowel
obstruction. Impression:
possibly misinterpret the 2. Enteritis. Findings compatible with
study (both shown here) GVHD.

11. REMEMBER YOUR PATIENTS
SUBOPTIMAL IMPRESSION
Findings:
PREFERRED
There is a mixed sclerotic
DICTATION
nidus within the superior
aspect of the T12 vertebral
Findings:
body with surrounding
…
peripheral reactive
sclerosis.
Impression:
Impression: Successful RF ablation
Vertebral body
Vertebral body lesion that
osteoid osteoma
may represent an osteoid
osteoma, but a malignant
tumor is not excluded.
• When findings are classic (even in a rare location—first SUBOPTIMAL DICTATION
case), commit to the diagnosis
Impression:
• Caveats & hedging can cause unnecessary patient concern Femoral stress fracture.
• Suboptimal reports may lead to patient complications
PREFERRED DICTATION
(conservative treatment for supposed “stress fx” instead of
bisphosphonate fx may cause a displaced fx—2nd case) Impression:
Femoral fracture related to
• Patients are increasingly reading reports, thus radiologists bisphosphonate therapy.
must keep this in mind

12. STRUCTURED REPORTING
Clinical history: 33 M with left hip pain after trauma
Findings: •Structured reporting is becoming more common
Alignment: Normal.
Labrum: Normal.
• Major advantages include uniformity & ensuring all
Cartilage: Normal. findings are included (e.g. soft tissue hematoma may be
Muscles/tendons/entheses: Normal. easily missed in this case)
Bones: Normal.
Vessels/nerves: Normal. • May suit certain studies more than others
Soft tissues: There is a well-circumscribed mass in
the anterolateral left thigh that is isointense to
muscle on T1, primarily hyperintense on T2, and
shows minimal peripheral enhancement.
Impression: Morel-Lavallée lesion

13. MEDICOLEGAL
SUBOPTIMAL DICTATION Does not
mention
Cyst in lateral kidney. possibility of
Additional low-density neoplasm
lesion in anterior kidney
that may be a hemorrhagic Does not give
cyst, but follow-up can be time interval
done to ensure stability. for follow-up
Berlin L. AJR 2002
3 years later—large RCC
Clinical History: Elevated β-hCG
SUBOPTIMAL IMPRESSION
Findings:
There is no IUP. There is an
echogenic mass adjacent to
right ovary.
Does not document
Impression: communication to
Findings compatible with clinician
ectopic pregnancy.

14. MEDICOLEGAL (Cont.)
• Don’t assume clinicians will understand what you imply
or may seem obvious. There is usually a different story in
the courtroom…
• Be specific in your reports for thoroughness, but also for
litigation purposes
• Communicate and document critical findings
• Recommend additional studies/interventions when
appropriate (may vary on referring clinician, i.e. generalist
vs specialist)
• Remember that our ultimate duty is to our patients

15. TAKE-HOME POINTS
1. Education on radiology reporting is essential for
trainees’ education.
2. Radiology residents should understand the nuances
of dictating that will make them more effective
radiologists.
3. Structuring meaningful and clear reports benefits
patients, referring clinicians, and other radiologists,
thereby improving patient care, streamlining diagnosis
and treatment, and heightening radiologists’ role in cost
containment.