刘翔伦敦英文医学影像报告的书写方法

2021年1月27日发(作者：皇叔宠妃悠着点)
英文影像报告的书写方法


随着对外交流的增多，
我们大家面对如 何书写好英文放射报告的
问题，
英文报告和中文报稿有许多相同的地方，
其实英文报告 中的问
题也常常是我们中文报告的通病。
1988
年发表在
RADIOLOG Y
上的
一
篇
文
章
(1988
Dec;169(3):ogy
reporting:
attitudes
of
referring
physicians
)
列出了一 所国外大学医院临床医生对放射科报
告的满意程度，
我们可以看出下列这些意见和我们一些医院 内的问题
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.


那么什么样的报告是合适的呢？它大体上应该满足三个方面：

1
实效性：
be tailored to satisfy the need for timeliness,

2
互动性：
support
the
role
of
a
diagnostic
imager
as
a
physician
consultant by encouraging physician to physician communication
3
准确性：
minimize the risk of communication errors.


一般考量：

简洁：
Efficient
conveying
of
information
does
not
require
complete
sentences in a narrative style.
“
no evidence of malignancy.
”

冠脉旁路移植
(CABG)
充血性心力衰竭（ＣＨＦ）
Creutzfeldt-Jakob
disease
(CJD)
CT,
or
MR
XRT
=
腹部放疗
.
smallbowel
obstruction
(SBO)
。

Single-sentence paragraphs in the
“
Impression
”

of the report
are particularly vexing .

现在一般时：
The
present tense
is
always
preferable and is appropriate
despite the fact that every examination or procedure is performed before
the dictation

语态：
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
研究表明具体格式
因情况不同而异。



“
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
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 ”

主要组成：

?

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.
次选的格式
:
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
注意事项
:
简洁
.
Clinicians
have
been
asked
what
they
want:

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.

is
an
area
of
linear atelectasis in the right lower lobe
-
right lower lobe.
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).
最重要的发现
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.
对比：
Lack of comparison is a common factor in the loss of a malpractice
lawsuit.
要求进一步检查：
Call Results for unexpected, life- threatening problems.
Document the call in the report.
斟酌用词，避免医生造成不利：
- A common phrase
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
overlooked,
not
appreciated,
obviously
present,
should
have
been
identified
避免含糊其词：

Avoid

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.
时
间
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.
可省略的词
: 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.

避免重迭用词：
such
as
oval
in
shape,
close
proximity,
small
in
size,
slightly
anechoic,
direct
comparison,
interval
change,
time
period,