Structure and content of radiology reports, a quantitative and qualitative study in eight medical centers

In order to determine how the quality of the radiology report can be improved, the variation in content, form and length of the report needs to be examined. The purpose of the present study was to investigate and compare the length and structure of radiology reports (reports of abdominal CT examinations) in eight hospitals in the Netherlands and Flanders, the Dutch speaking part of Belgium.

Eight hundred reports--100 from each collaborating center--were collected. After exclusion of the reports that did not fulfill the criteria for a standard CT examination of the abdomen, 525 were retained for further study. The structure of each report was analyzed and the constituting parts (technical information, description of the findings, conclusion, advice, remark, note) were determined. The character and word count of the report and its constituting parts were measured and the results were grouped according to the country (Netherlands vs. Belgium/Flanders), the qualification of the radiologist (staff members vs. residents.) and the nature of the hospital (university medical centers vs. community hospitals).

Statistically significant differences were found between the Netherlands and Flanders, and between staff members and residents. The authors also found a wide variety in the lay-out and the overall content of the radiology report.

While most of the differences we found are probably rooted in local tradition, a standard model for the radiology report in centers sharing the same language may be a means to avoid interpretation mistakes by referring physicians, and to promote better care.