Actionable reporting: Audit of radiology reports at a Tertiary Care Hospital.

Abstract

Purpose: To assess the radiology reports in department by focusing on three major parameters:1.Answer to the clinical question/s asked by the referrer. 2. Tentative diagnosis and/or differential diagnosis. 3. Suggestion for the next appropriate step.

Material and methods: This study was conducted at Radiology department of Tertiary Care Hospital in Peshawar and data of 100 patients was randomly collected from hospital’s Health Management Information Systems (HMIS), spanning from May to September 2020. Out of 100, 24 were Ultrasound reports, 44 were CT scan reports and 32 were MRI reports. Reports were checked whether the concluding remarks had answered the clinical question, listed any diagnosis or differential diagnosis and suggested some future advice or not. Confidentiality of the patients was made sure.

Results: Data of 100 radiology reports was obtained. Clinical question asked by the referrer clinician was answered in 100% of the reports. 56% of the reports contained a tentative/differential diagnosis (modality wise: U/S (37.5%), CT (45.4%), MRI (81.2%)) and 48% reports had advice about the next appropriate step. 100% of ultrasound reports contained an answer to the question asked by the clinician, 25% with a differential diagnosis and 50% of the reports had some advice about the next best step.

Conclusion: We concluded from our results that the radiology reports are being focused mainly on answering the question asked by the clinicians, which is internationally accepted Radiology Report Standard, however the remaining parts of a standard actionable report was found to be ignored in a huge number of cases.

Keywords: Radiology, Reports, Diagnosis