Radiology Report Structure

The radiology report is where the radiologist doctor places his interpretation of your imaging test. The radiology report will often have your unique identifying information like your medical record number, your date of birth, etc. The name of the procedure will be listed. Often radiologists will describe the technique and whether any contrast was given.

The radiologist will often then have a section where he will describe the findings of your exam. This will often sound like medical jargon. Here the radiologist is describing in detail exactly what he is seeing. This provides someone who has not seen the images an idea of what exactly is seen on the images. This section can be short if everything looks normal to very long if there are complex findings or prior exams to compare to.

The next section will be the conclusion or the impression. This is where the radiologist will provide his interpretation of your exam. He will try to make a diagnosis or provide a set of possibilities. If your being treated for a condition, then he may state whether anything has changed.

In some cases, the radiologist may provide recommendations for further testing. This is sometimes the case when something on the imaging test is not clear or can further be clarified with another imaging test. In some cases this may involve a biopsy or a consultation with another specialist.

Follow up study in a certain time period may be another recommendation by the radiologist. This is done for abnormalities which don’t necessarily need to be acted on right now, but may turn out to be something in the future. If something is truly important, it will most likely grow or change in someway.

Your doctor will use the report of your imaging test for treatment and guidance on what to do next. Your doctor will also use your clinical information in conjunction with the test result to make sure you get the best care.

Disclaimer: The content of this website is provided for general informational purposes only and is not intended as, nor should it be considered a substitute for, professional medical advice. Do not use the information on this website for diagnosing or treating any medical or health condition. If you have or suspect you have a medical problem, promptly contact your professional healthcare provider.

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