Understanding how to read a radiology report is critical for ensuring quality patient care. It helps us interpret the results of radiological imaging procedures to accurately diagnose diseases, abnormalities, and injuries, which is essential for determining the course of treatment for that patient.
We will describe the different sections of a radiology report, what they mean, and what kind of information each section contains. In many cases, we will also give hypothetical examples of what that section may say.
Understanding the Main Sections in a Radiology Report
Radiology is a medical imaging procedure that uses ionizing electromagnetic radiation to create images of bones, organs, and soft tissues to diagnose diseases, abnormalities, or injuries.
Radiology medical imaging involves a wide range of radiology equipment using various techniques for an even wider range of diagnostics. A radiologist performs or supervises these procedures, then studies and interprets the images and produces a report based on their findings that is then given to the doctor or healthcare provider who ordered the exam.
The report often contains complex information since it is intended for medical doctors to read. Here, we will break down the main sections of a radiology report to help you better understand the results.
Type of Exam
This section shows what kind of exam was done along with the date and time of the exam. For example, it may say something like:
“Multiple axial CT images were obtained through the abdomen and pelvis after
administration of oral contrast material performed on July 19, 2024.”
Indication
The indication section, sometimes also called clinical information or patient history, provides a concise description of the patient’s history and the clinical reasoning that led to the request for imaging. This section allows the healthcare provider to quickly communicate to the radiologist the reason for the exam to help improve their diagnostics and focus their report on the specific symptoms in question.
The radiologist may add additional information that they find in the patient’s chart before the imaging tests are performed. Note that while this section helps the radiologist pinpoint what they are looking for, they are also trained to analyze everything on the images so they don’t skip what could be important details just because they were not indicated on the patient’s clinical records.
An example of the indication section might be something as simple as this:
“Suspected fracture in the lateral malleolus.”
Technique
The technique section describes how the exam was done, giving more details than the type of exam section. It is intended for documentation purposes to describe what exactly was done, as this can be helpful for a radiologist when future exams may become necessary to prevent duplication of imaging techniques.
The technique will include the imaging technique employed, such as X-ray, CT, MRI, etc., as well as the details of the imaging sequences or specific views done, such as the different angles used in X-rays or the slice thickness or reconstructions used in CT scans. It may also include information about the specific imaging equipment used (model, year), whether or not contrast agents were used, and how any contrast agents used were administered.
Finally, it also sometimes includes details of any limitations or challenges that could affect the image quality, such as obesity or breathing difficulties during the procedure.
A straightforward example from a dental technique might be:
“Cone beam CT images in the bone window in the axial, coronal, and sagittal planes.”
Comparison
The comparison section provides information about previous imaging studies that were used to compare with the current study. Naturally, this section will only be filled in if there is a past history of imaging.
Here, the imaging modality (e.g., CT, MRI, X-ray) and the date of the previous study will be specified. Additional information about the limitations or challenges of making the comparison may also be described.
Comparisons are important in enabling the radiologist to provide a more accurate assessment by considering how the findings may have changed from the past to the present.
An example of this section may say something like this:
“A comparison was made with a cervical spine MRI performed on April-10-2022.”
Findings
An integral section of the report, where the radiologist describes their findings from the images in detail.
Some radiologists will report their findings in paragraph form, while others list each organ or region of the body with a summary of the conclusions after each one. If nothing abnormal is seen, they will report it as “normal” or sometimes “unremarkable.” Otherwise, abnormalities, diseases, or injuries will be reported in more detail.
An example of a cardiac exam might say something like this:
“The base of the heart is within normal limits. No pericardial effusion detected.”
Impression
In the impression section, the radiologist summarizes the findings and reports the most important results they observed. They also typically suggest possible causes of those results, called a differential diagnosis. The impression may simply state that no findings on the images could account for the clinical symptoms presented.
It may include a clinical correlation to the patient history and recommendations for further imaging techniques, procedures, or consultations based on their findings.
This section helps guide the medical practitioner in decision-making, including treatment methods or additional investigations that may be needed.
An example of an impression might be something like this:
“No acute abnormalities in the abdomen or pelvis. Colonic diverticulosis without evidence of acute diverticulosis.”
Frequently Asked Questions
What Do Findings Mean on a Radiology Report?
The findings refer to a section on a report that describes what the radiologist observed on the images, whether normal or abnormal results were found. The radiologist may write it in paragraph form or break it down by organ or region of the body to describe the results to the doctor who ordered the exam.
What Is the Interpretation in the Radiology Report?
The interpretation is the radiologist's expert assessment of the images they observed. Their interpretations will appear in the findings and the impression sections of the report or may appear elsewhere in the medical record.
Final Thoughts
Understanding the sections of a radiology report is critical for medical practitioners to determine the next course of action, whether treatment (the results were conclusive) or additional tests are required in cases where the results did not find the cause of the clinical symptoms.
Using quality radiology equipment will help provide the most rapid and accurate results, allowing for improved diagnostics and patient care. Contact Maven Imaging today for all your radiological equipment needs.
