Critical finding capture in the impression section of radiology reports

Radiology reports communicate imaging findings to ordering physicians. The substantial information in these reports often causes physicians to focus on the summarized "impression" section. This study evaluated how often a critical finding is documented in the report's "impression" section and describes how an automated application can improve documentation.

A retrospective review of all chest CT scan reports finalized between October, 2009 and September, 2010 at an academic institution was performed. A natural language processing application was utilized to evaluate the frequency of reporting a pulmonary nodule in the "impression" section, versus the "findings" section of a report.

Results showed 3,401 reports with documented pulmonary nodules in the "findings" section, compared to 2,162 in the "impression" section - a 36.4% difference.

The study revealed significant discrepant documentation in the "findings" versus "impression" sections. Automated systems could improve such critical findings documentation and communication between ordering physicians and radiologists.