Radiology Written Report Guideline
Feedback Survey
The RANZCR Radiology Written Report Guideline, approved in 2011, is due for review.
As part of this review process, we are requesting feedback from RANZCR Fellows and trainees,
as well as referrers, regarding the current recommendations, a proposed new recommendation
and any suggestions regarding additions, subtractions or changes to the existing
recommendations or any other aspect of the guideline.
The full guideline document is accessible here: Guidelines for the Written Radiology Report
We anticipate the survey to take 10-15 minutes to complete and encourage you to peruse the
full guideline document first, if possible, as this will reduce the time taken to complete the
survey. Once you have started the survey, you must complete it in one sitting. After submitting
your finished survey, you will not be able to access your answers.
Many thanks,
The RANZCR Quality and Safety Committee
Level 9, 51 Druitt Street, Sydney NSW 2000, Australia Ph: +61 2 9268 9777 Fax: +61 2 9268 9799
Web: www.ranzcr.edu.au Email: ranzcr@ranzcr.edu.au ABN 37 000 029 863
Section 1: WRITTEN REPORT CONTENT
The following recommendations focus on what should be included in the content of the report.
A comment field has been provided below each recommendation for any comments or
suggestions.
1.1
Patient demographics / report status
The report should include:
 Patient identification details;
 Examination type, date and time; and
 Report status.
If the report is preliminary and awaiting approval or finalisation by another radiologist this
should be clearly stated.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
Click here to enter text.
1.2
History / clinical information
The clinical information from the written referral or other sources, and its interpretation by
the radiologist, should be included in the written report.
The source(s) of this information should be clearly stated if this was not the written referral.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
Click here to enter text.
1.3
Comparison with prior studies
A specific statement should be made about the existence and availability for review of
previous imaging relevant to the current examination.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
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1.4
Technique
1.4.A Technical details
The examination technique should be documented. This should include:
 the nature and type of contrast agent(s) and / or radiopharmaceuticals including
route(s) of administration; and
 the nature and type of any adverse reaction(s) to contrast media:
o how this was treated; and
o what information was given to the patient at the time, particularly regarding
implications for future contrast administration.
Do you agree with this recommendation?
☐
Yes
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☐
No
Comments
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1.4.B Procedural description
All relevant procedure-related information should be provided - any immediate or
delayed procedural complications and how these were managed should be described in
the report.
If a procedure has been requested in conjunction with a diagnostic study, and the
procedural component was not / could not be performed, the reasons for this should be
stated.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
Click here to enter text.
1.5
Examination quality
If the overall examination is not good quality, the nature of the limitations should be stated
and how these limitations could adversely affect interpretation should be explained.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
Click here to enter text.
1.6
Findings
Relevant imaging findings should be characterised as specifically as possible including
description of:
 precise anatomical location using accepted modality - specific best practice;
 size or extent;
 shape, where relevant; and
 other anatomical / pathological characteristics relevant to diagnosis or treatment.
Normal findings should be noted when:
 the absence of abnormality has direct bearing on diagnosis or subsequent
management;
 the absence of abnormality is part of the recognised staging of the severity of a
disease process;
 the report takes the form of an itemised checklist, and omission of a specific
statement about the normality or abnormality of a standard item can create
ambiguity of meaning; and
 the clinical situation of the patient suggests that certain relevant negative
information would be useful to the referrer.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
Click here to enter text.
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1.7
Addressing the clinical question / differential diagnosis
1.7.A Addressing the clinical question
Specific clinical questions asked by the referrer should be addressed wherever possible in
the conclusion of the report.
When it is not possible to answer these specific clinical questions, the reason(s) for this
should be clearly stated.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
Click here to enter text.
1.7.B Diagnosis / differential diagnosis
A specific diagnosis(es) for the observed imaging findings should be provided whenever
possible. When a number of possibilities exist, these should be stated and their relative
likelihood should be described.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
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1.8
Conclusion / opinion / impression
The conclusion should provide a concise, clinically contextualised interpretation of the
previously described imaging observations.
If findings are normal or non-significant, this should be stated explicitly.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
Click here to enter text.
1.9
Recommendations (for further testing, treatment, referral etc)
If further imaging, investigations, referral or treatment is to be suggested, the report should
describe:
how it is expected that this will contribute to the diagnosis and / or management of
the patient’s current medical problem;
the exact nature of the further investigation / referral / treatment that is recommended;
and
the suggested timing of this further investigation / referral / treatment if relevant,
especially if this is urgent.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
Click here to enter text.
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1.10 Discrepancy documentation
When an initial report (verbal or written) about an examination is provided and the final
report differs in a manner that could alter diagnosis or management, it is the responsibility of
the radiologist to ensure that:
 the discrepancy is documented in the written report (either as an amendment to the
existing report or as a new report indicating the discrepancy); and
 people involved in the care of the patient are made aware of the discrepancy and
the notification process is documented.
Discrepancy documentation should be clearly separated from the original report and be
added as an addendum with a date, time and authorship of the radiologist providing the
addendum.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
Click here to enter text.
Section 2: FORMAT OF REPORT AND STYLE OF
EXPRESSION
2.1 Format
2.1.A Length
Reports should be as concise as possible while still conveying the information required
to highlight key findings and to answer the clinical question.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
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2.1.B Templates
Standardised examination / disease process - specific report templates should be
developed to meet the needs of specific referrer groups.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
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2.2 Terminology
The written radiology report should use terminology with commonly agreed meaning.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
Click here to enter text.
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2.3 Clarity, certainty and readability
The written report should:
 use short sentences in preference to long sentences in prose reports and in the
free text fields of itemised reports; and
 avoid low confidence modifiers such as “might be consistent with” and “possibly
represents”.
Radiologists should review and edit their own reports and those of trainees under their
supervision to improve accuracy, clarity, readability, succinctness and logical order of
examination findings, and their interpretation before finalising the report.
Do you agree with this recommendation?
☐
Yes
☐
No
Comments
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NEW RECOMMENDATION TO EXISTING GUIDELINE
The following additional recommendation to the content section of the report guideline has been
suggested by a number of individuals since the guideline was first published in 2011.


If an urgent or critical result / procedural complication has been notified to the referrer (or
others involved in the care of the patient) the name of the contacted person(s) and the
mode, time, and date contact was made, and by whom, should be recorded in the written
report.
If the original report was made available in print or electronically prior to this critical result /
complication being notified, details of notification, as indicated above, should be added as
an appendix or published as a separate, supplementary report”
Do you agree that this would be a useful addition?
☐
Yes, essential
☐
Yes, desirable
☐
Yes, but not that important
☐
No, not important
☐
No, should not be included
Comments
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SUGGESTED RECOMMENDATIONS
Do you have any suggestions for additional recommendations or other changes / additions to
the guideline form or content?
Click here to enter text.
Any other suggestions?
Click here to enter text.
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GUIDELINE USAGE
Have you implemented the Radiology Written Report Guideline in your daily practice?
☐
Yes
☐
No
☐
N/A
If yes, please let us know how:
Click here to enter text.
ABOUT YOU
To assist the process of reporting on the consultation process, it is essential to record a number
of details about those who provide feedback on this guideline.
Your assistance with providing the following details is sincerely appreciated.
Where do you live?
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ACT
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NSW
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NT
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QLD
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SA
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☐
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☐
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TAS
VIC
WA
NZ
Other
Please specify.
How would you describe where you live?
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Major city
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Rural setting
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Minor town
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Remote location
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Small town
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Other
Please specify.
What group do you consider best describes your perspective when providing your feedback to
this guideline?
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Consumer (patient, family and/or carer)
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Health practitioner
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Medical practitioner
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Other
Please specify.
What best describes your profession?
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General practitioner
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Physician
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Surgeon
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Other
Please specify.
Radiologist
Radiation oncologist
Allied health
How many years have you been working in this field?
☐
Less than one year
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1-5 years
☐
5-10 years
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10-20 years
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20-30 years
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More than 30 years
What best describes the nature of your health care practice:
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Public
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Private
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Both private and public
Where do you provide the majority of your health care services?
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ACT
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TAS
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NSW
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VIC
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NT
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WA
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QLD
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NZ
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SA
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Other
Please specify.
Thank you
Thank you for completing this feedback.
Your responses will be provided to the RANZCR Quality and Safety Committee for
consideration in reviewing the guideline document.
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