Indication on a radiology report is the reasons why the study is being done. Indication is usually specified by the ordering provider. Indications are also placed into the radiology report as this is often a requirement for billing and helps the radiologist focus on the problem at hand.
What are examples of indications in radiology reports?
Indications can vary from being highly detailed to short codes or something completely irrelevant. Sometimes radiologists have to look into the medical record or even call the radiology provider to find out why the exam is being done.
Indications in the radiology report are helpful for the radiologist to know what to focus on. For example, if the indication is right lower abdominal pain, the radiologist will focus his attention to that area of the abdomen and try his best to explain the patients symptoms.
Other indications may be assess response to treatment for cancer. In these cases, the radiologist will carefully measure the cancer and see if it has responded to the treatment. Indications for cancer may also include staging of a newly diagnosed cancer. This means that a cancer has been diagnosed and we want to see if it has spread.
Indications from the emergency room may be things like fall, car accident, or fight. In these cases, the radiologist will look for fractures of bones, bleeds and injury to organs. The more detailed the indications the more helpful. For example, it is more helpful to know that the right 11th rib is tender rather then just pain or rib pain.
Some indications in radiology reports are not helpful
Indications in radiology reports sometimes are not helpful or are unrelated to the real reason the exam is being done. This may be because the indication is entered by a computer system or an office staff who has no medical background. The radiologist will often notice these types of indications and will look in the chart for help.
Some of these unhelpful indications may be ICD diagnostic codes, single words like pain or numbness, or unhelpful phrases like screening encounter. In these cases, A look in the medical chart at the ordering doctors note will help get the real reason for the exam.
Inaccurate indications in radiology reports
I have also seen indications which are not accurate. Like history of thyroid cancer when the patient has a different cancer or no cancer. Headache when there is no headache specified by the patients. Trauma when there is no significant recent trauma. I am not sure why this happens but it does.
Having inaccurate indications in the medical record can have consequences. The referring doctor or patient can have this corrected in the radiology report. Incorrect indications can have consequences for insurance and treatment purposes.
Indications in a radiology report are an important component. This lets the radiologist know why the study is being done. It helps the radiology doctor focus on the most important problem. The report will be focused on answering the question or indication for the study. The more information given to the radiologist, the better.