The indication for a radiology report is the reason for the exam. This is often included in the radiology report at the beginning or top of the report. The indication can be a symptom, finding on a physical exam, a finding on a prior test, in addition to other possibilities.
Why is the clinical indication needed?
The clinical indication for an exam is also often required for billing. Insurance companies often require an appropriate indication to pay for an exam. An exam without an appropriate indication may not be covered for payment.
An indication also is important for the radiologist to know. Although the radiologist looks at every corner of every exam, it helps him to focus on certain anatomy which may be responsible for the symptoms.
For example, right lower abdominal pain as an indication will tell the radiologist that he must look carefully at the structures in that part of the abdomen. Subtle abnormalities may begin to carry more significance if the symptoms are referable to that region. An appendix which is only slightly dilated may mean early appendicitis rather then a normal variation.
A clinical indication may also be from a physical exam finding. For example, a gynecologist may feel an enlarged uterus or pelvic mass and want to know exactly what is going on. An enlarged uterus may be from fibroids. There may be a tumor in the pelvis.
Clinical indications are also sometimes from other imaging exams. For example, an X-ray of the chest may show a nodule or spot in the lung. A chest CT will often be the next step to look at it more closely and see if it truly is a nodule or something else responsible for causing the shadow on the chest X-ray.
Rule out as a clinical indication
Clinical indications are sometimes simply to rule out some condition. Like a study ordered to rule out a pulmonary embolism or appendicitis. This is the least helpful clinical indication both for the purpose of billing and for the radiologist. Thankfully, most places now use electronic records where the radiologist can look up the patients complaints.
A clinical indication is therefore one of the most important parts of the exam. The radiologist will often try to answer the clinical indication as one of the first impression points. This is the main reason the exam was ordered. The clinical indication is also important to the radiologist to provide the most clinically relevant read possible.