Increase in definitive language in rad reports benefits clinicians

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 - Report

A study recently published by Journal of the American College of Radiology reveals promise through a trend of increased definitive reporting, while also calling for further education and training in reporting for radiologists. 

The overall aim of the study for researchers from Georgetown University was to measure the number of times certain terminology was used in abdominopelvic CT reports before and after being edited under reporting template guidelines by a radiology professional.  

"In an era of radiology reporting that is moving toward more standardized language and clarity for referring physicians, we sought to examine our patterns of language use, using the term normal as a marker of definitive, standard language and the term unremarkable as a marker of less definitive language," said Susan M. Ascher, MD, an author of the study and radiologist from MedStar Health. "Vocabulary preferences among referring physicians have not yet been studied formally in radiology reporting, but expert opinion and studies from pathology reporting demonstrate that there is a need for improving communication in reporting by enhancing clarity."  

An automated computer program methodically analyzed 1,753 radiology reports (878 of which were "pre-template" reports and 875 "post-template" reports) for word count, the number of times words were changed before and after each report was edited, and how often the words "normal" and "unremarkable" appeared.  

According to the study, researchers hypothesized that in "post-template" reports, the use of the term "normal" would increase and the use of the term "unremarkable" would decrease.  

Although researchers did not find any significant change in word count or number of changes between "pre-template" and "post-template" reports, the frequency of the word "normal" increased a significant amount, from 5.29 time per "pre-template" report to 8.92 per "post-template" report. The number of times the term "unremarkable" was used showed no significant increase.  

"The increase in normal in post-template reports reflects a trend toward more definitive reporting, which may increase clarity and satisfaction among referring physicians," Ascher her team concluded from the study. "The increased use of the less definitive term unremarkable identifies an area in need of further training and improvement in our department."