J Korean Soc Radiol.  2009 Oct;61(4):263-268. 10.3348/jksr.2009.61.4.263.

Analysis of the Radiology Reports from Radiology Clinics

• Kim EJ
• Kwack KS
• Cho JH
• Jang EH

• KMID: 2209026
• DOI: http://doi.org/10.3348/jksr.2009.61.4.263

Abstract

PURPOSE
The purpose of this study was to investigate the form and content of the radiology reports from radiology clinics in Korea.
MATERIALS AND METHODS
One hundred and sixty six radiology reports from 49 radiology clinics were collected, and these reports were referred to the academic tertiary medical center from March 2008 to February 2009. These included reports for CT (n = 18), MRI (n = 146) and examinations not specified (n = 2). Each report was evaluated for the presence of required contents (demographics, technical information, findings, conclusion, the name, license number and signature of the radiologist and the referring facility). These requirements were based on the guideline of the American College of Radiology and the previous research.
RESULTS
The name of the patient, the gender, the body part, the type of examination, the time of examination and the conclusion, the name of the radiologist and the name of facility were well recorded in over 90% of the radiology reports. However, the identification number of the patient, the referring facility, the referring physician, the use of contrast material, the clinical information, the time of dictation, the signature of the radiologist and the license number of the radiologist were poorly recorded (less than 50%).
CONCLUSION
The optimal format of a radiology report should be established for reliable and valid communication with clinicians.

MeSH Terms

Guideline Adherence
Humans
Licensure
Medical Records