Medical Transcription: Radiology and Imaging Reports
Radiology and imaging reports show up commonly in medical transcription work. Here are the basics about these types of reports and how to transcribe them.
Plain X-rays, MRIs, CT scans, and ultrasounds are just a few of the multitude of techniques used to diagnose and treat our diseases and injuries. They offer the power to visualize and reach parts of the body without resorting to surgery for a direct inspection — a definite plus for the patient!
Imaging studies often involve a contrast medium, or dye, either taken orally by the patient or injected. The distribution of the dye highlights particular anatomic features, making them easier to identify and examine.
Imaging technologies also are used during surgery to guide the movement of surgical instruments or deliver a treatment to a particular body part without creating any substantial holes to get there.
For example, if a patient has a suspected heart attack, an interventional radiologist can insert a catheter via a small incision in the patient’s leg, direct it through the arterial system to the heart, and use it to identify and remedy any blockages, using imaging to direct every step.
Radiology and imaging reports record
The type of imaging study performed and body part being studied
The quantity and type of views recorded
Contrast materials or medications used
The reason for the study
A description of the test process, if relevant
The results of the study
Conclusions and recommendations
A study can have multiple parts. Often initial images will be recorded; then some change will be made, such as manipulating the patient’s limb, having him run on a treadmill, or administering contrast dye or medication; and then repeat images will be taken.
Imaging studies are sometimes dictated as operative reports or procedure notes, particularly if the procedure was performed in an operating room, as may be the case with a procedure that involves anesthesia or accessing a region deep inside the body, such as the spine or heart.
The initial section of a radiology report relays the specifics of the study. It describes the types of images obtained, contrast material or medications used, and any relevant circumstances/comments, such as bowel preparation protocol for a colonoscopy.
PROCEDURE: MRI, left knee, without contrast.
If the results are being compared to results of a previous study, the date and name of the comparison study will be given here or under a Comparison heading.
Reason for study
This section briefly states the reason for the study. Alternative titles include History, Clinical History, or Indication. This tends to be a few words or a few sentences at most, like this:
REASON FOR STUDY: Chest pain.
The patient is a 70-year-old man with worsening lower back pain and bilateral lower extremity weakness.
This section describes how the procedure was performed, along with the nature of the images obtained. For something straight-forward, like a plain X-ray, it will be as simple as:
TECHNIQUE: PA and lateral views were obtained.
A complex procedure, such as cardiac angiography, may include a step-by-step narrative that runs several paragraphs long.
What’s a view? Think of an X-ray machine as gun and the film that records the image as a target. Picture yourself standing between the gun and the target while someone pulls the trigger. If you’re facing the gun, then the X-rays will pass through your body from front (anterior) to back (posterior) on the way to the target (the film).
The resulting image is called an AP (anteroposterior) view. If you turn sideways to the gun, the X-rays will shoot in one side of you and out the other, creating a lateral (from the side) view. If you position yourself at a 45-degree angle to the gun, the X-rays will pass through you at an angle, creating an oblique view. Get the picture?
The measurements, values, and observations recorded during the study are reported here. This section also may be titled Interpretation or Results. The findings may be presented in a narrative format, a series of subheadings with associated values, or a combination. The format is highly dependent on the type of study and facility preferences. Here’s an example of renal ultrasound findings:
The right and left kidneys measured 4.9 and 5.0 cm in length, both near the lower limit of normal in size. The kidneys are otherwise normal in appearance and normal in position. The bladder is full and normal appearing on transverse images.
Incidentally, there is a low-attenuation mass measuring 1.7 x 1.4 x 1.8 cm within the inferior aspect of the left lobe of the liver.
Occasionally a study uncovers something unrelated to the condition that prompted the investigation, like the liver mass in the example above. These are referred to as incidental findings. Tumors (usually benign) are found by coincidence commonly enough to have an official name: incidentalomas.
The report concludes with the radiologist’s assessment of the significance of the findings. It can be as specific as a list of diagnoses or a more general “is suggestive of” narrative.