隨著對(duì)外外交流的增多，我們大家面對(duì)如何書(shū)寫(xiě)好英文放射報(bào)告的問(wèn)題，英文報(bào)告和中文報(bào)稿有許多相同的地方，其實(shí)英文報(bào)告中的問(wèn)題也常常是我們中文報(bào)告的通病。1988年發(fā)表在RADIOLOGY上的一篇文章(1988 Dec;169(3):825-6.Radiology reporting: attitudes of referring physicians ) 列出了一所國(guó)外大學(xué)醫(yī)院臨床醫(yī)生對(duì)放射科報(bào)告的滿(mǎn)意程度，我們可以看出下列這些意見(jiàn)和我們一些醫(yī)院內(nèi)的問(wèn)題是一致的。
49% said the reports usually were clear,
40% thought the reports were occasionally confusing.
49% thought the reports sometimes did not sufficiently address the clinical questions.
32% preferred the summary statement to be at the beginning of the report,
29% preferred this portion at the end.
16% thought that it took too much time to receive the reports.
那么什么樣的報(bào)告是合適的呢？它大體上應(yīng)該滿(mǎn)足三個(gè)方面：
1實(shí)效性：be tailored to satisfy the need for timeliness,
2 互動(dòng)性：support the role of a diagnostic imager as a physician consultant by encouraging physician to physician communication
3準(zhǔn)確性：minimize the risk of communication errors.
一般考量：
簡(jiǎn)潔：Efficient conveying of information does not require complete sentences in a narrative style. “no evidence of malignancy.”
冠脈旁路移植(CABG) 充血性心力衰竭（ＣＨＦ)Creutzfeldt-Jakob disease (CJD) CT, or MR XRT =腹部放療. smallbowel obstruction (SBO) 。 Single-sentence paragraphs in the “Impression” of the report are particularly vexing .
現(xiàn)在一般時(shí)：The present tense is always preferable and is appropriate despite the fact that every examination or procedure is performed before the dictation
語(yǔ)態(tài)：Comparisons can be dictated “there is” rather than “there has been” no change. Avoid the passive voice “is seen.”
格式
Header
Demographics
a. The facility or location where the study was performed.
b. Name of patient and another identifier.
c. Name of referring physician or other healthcare provider. If the patient is self referred, that should be stated.
d. Name or type of examination.
e. Date of the examination.
f. Time of the examination, if relevant (e.g., for patients who are likely to have more than one of a given examination per day).
g. Inclusion of the following additional items is encouraged:
i. Date of dictation
ii. Date and time of transcription
iii. Birth date or age
iv. Gender
History (Indications or Symptoms)
Keep it short. Remember, restating the same information is noncontributory to the ordering physician. Do not repeat the age and sex of the patient when this information is already included in the header. If pertinent history is not provided, this omission should often be explicitly stated in the report. This recommendation reflects current medicolegal advice, sends a subtle message to the ordering physician, and may appropriately convey diagnostic uncertainty
Body of the Report
一篇AJR Am J Roentgenol. 1995 Oct;165(4):803-6研究表明具體格式因情況不同而異。
“preferences of referring physicians for the extent of description of imaging findings included in radiology reports depend on the clinical circumstances. In the specific clinical scenarios examined, physicians preferred that the report include a brief description of the findings, except for screening chest radiographs, for which "normal examination" was an acceptable report. The referring physicians' preferences regarding the amount of descriptive detail included in the report were independent of their specialty, academic status, and experience ”www.med126.com
主要組成：
description of technique
quality
limitations of the examination
description of radiologic findings
diagnostic impression
differential diagnosis
recommendations for further investigations
普遍的格式:
Discussion:
Impression
This is logical and follows the inductive method. The facts are weighed and a conclusion made. In the modern hospital environment it has disadvantages. Those listening to the report have to wait until the end to hear the conclusion. The same problem is inherent in reading reports online, the referring clinician may have to scroll, or worse, page to the conclusion.
次選的格式:
Diagnosis or Findings
Discussion.
This reverse logic brings the most important information to the top where it is seen or heard first. This is the format preferred by the referring clinician.
Description of technique
The report should include a description of the studies and/or procedures performed and any contrast media (including concentration, volume, and route of administration when applicable), medications, catheters, or devices used, if not recorded elsewhere. Any known significant patient reaction or
complication should be recorded. Detailed technical descriptions are less necessary as examinations become more commonplace.
Findings and Discussions
注意事項(xiàng):
簡(jiǎn)潔. Clinicians have been asked what they want: "brief description of the radiographic findings." Lawyers will argue that reports should be wordy as a defense against malpractice. Short reports equate to haste and carelessness. However, long reports cost money to produce and read. Be succinct. Eliminate unneeded or redundant words. "There is an area of linear atelectasis in the right lower lobe" should be - "Linear atelectasis right lower lobe." Only pertinent negatives are appropriate. Redundancy may be necessary for billing purposes such as separate paragraphs for CT of the abdomen and pelvis, or for with and without contrast media.
Redundancy is common. Example: lung fields. Redundant (and silly concept). "The lung fields are normal" becomes "normal lungs".
最重要的發(fā)現(xiàn)FIRST： Normal except for cancer RLL is unacceptable. The physician may stop at normal.
定量：Measure if possible or use qualifiers- mild, moderate, severe.
對(duì)比：Lack of comparison is a common factor in the loss of a malpractice lawsuit.
要求進(jìn)一步檢查：Call Results for unexpected, life-threatening problems. Document the call in the report.
斟酌用詞，避免醫(yī)生造成不利：- A common phrase "fracture is poorly aligned" should be avoided. Describe the facts. Unfortunately it is not uncommon to find a new malignancy on a mammogram or chest radiograph which in retrospect was present and reported out by a colleague as "normal" Words or phrases to avoid: missed, error, mistake, overlooked, not appreciated, obviously present, should have been identified
避免含糊其詞： Avoid "if clinically indicated." Don't hedge. Put yourself in the referring physician's shoes. What would you conclude if you read this report?
不要混淆“Descriptions” 和“Impressions” ：This observational section of the report is for vascular congestion and consolidations, whereas the “Impression” is for congestive heart failure (CHF) and pneumonia.
時(shí)間日期：Numeric dating will be an increasing problem with teleradiology extending across national boundaries. July 8 may be 7/8 in the United States, but it is 8/7 throughout most of the world.
可省略的詞: this exam is provided, is obtained, is taken, or is submitted for interpretation; appearances are; a finding is seen, visualized, or identified; as stated above, as described above, or as noted above; please note, as noted, of note, or note is made of; is remarkable for; unremarkable; if clinically indicated; as well as; at this time; however; in addition to; in nature; otherwise normal; quite; unique; some and somewhat.
避免重迭用詞：such as oval in shape, close proximity, small in size, slightly anechoic, direct comparison, interval change, time period, interval comparison, previous history, previous exam of (date), and completely asymptomatic. “Total or partial occlusion” and “normally or abnormally dilated” are part of our everyday lexicon but are no less inappropriate. Avoid double negatives like “not uncommon” and “not rare”.
“護(hù)身符” 應(yīng)用：A “hedge” is an evasive statement to avoid the risk of commitment, and it has perhaps justifiably been called the tree of our specialty. A rule of thumb is not to use more than one hedge per sentence. Avoid “no overt evidence of CHF” and “no obvious pneumonia. necessary as examinations become more common hedge vocabulary includes density or opacity, apparent, appears, possible, borderline, doubtful, suspected, determinate, identified, seen, no definite, no gross, no obvious, no overt, no evidence of, no significant, possible, probable, suggested, suspected, suspicious for, vague, clinical correlation needed, and equivocal.
