A quality checklist for clear radiology reports

Why use a checklist for radiology reports at all?

A checklist is useful because it turns good intentions into a routine that works even when you are tired or busy. Experienced reporters know what a good report looks like, but a long list or a late shift makes it easy to skip a step without noticing.

Checklists also make quality visible. When everyone in a team checks the same points, reports become more consistent, and it becomes easier to discuss what good looks like without making it personal.

The best checklists are short. If a checklist takes longer to work through than the report took to dictate, people stop using it. Aim for a handful of points you can check in well under a minute.

• Catches small errors before they reach the referrer.
• Makes reports more consistent across a team.
• Works on busy days as well as quiet ones.
• Gives a shared language for discussing quality.

Are the patient and study details correct?

The first check is that the report belongs to the right patient and the right study. Everything else depends on this, so it comes before reading a single sentence of the findings.

Confirm the patient reference, the study type and the date. If the report mentions a comparison study, check that the date of the comparison is correct and that it is the study you actually looked at.

In Medicate, the demonstration data is fictional, but the habit is the same: look at the title and patient reference on the review screen before you begin checking the content.

• Patient reference matches the study.
• Study type and body part are correct.
• Study date is correct.
• Comparison study, if mentioned, is correctly dated.

Does the indication explain why the study was done?

A good indication states the clinical question in one or two sentences. It tells the reader what the referrer wanted to know, which frames everything that follows.

Avoid copying long request text word for word if a shorter summary captures the question. At the same time, do not drop details that change how the findings should be read, such as a relevant history mentioned on the request.

If the indication is missing or unclear, say so plainly rather than guessing. A report that states what was asked is easier to audit and easier to understand later.

• States the clinical question clearly.
• Keeps relevant history that changes interpretation.
• Avoids padding and repeated request text.

Is the technique described simply and accurately?

The technique section should record what was actually done, in as few words as needed. For many studies, one line is enough.

Include details that a reader might need to understand the findings, such as the views obtained, whether contrast was given or whether the study was limited in some way. A limitation that affects confidence belongs in the report, not only in your head.

Keep technique separate from findings. Mixing the two makes it harder for a reader to scan the report for what was seen.

• Views, sequences or phases are listed where relevant.
• Contrast use is stated where relevant.
• Limitations that affect interpretation are noted.

Do the findings read in a logical order?

Findings are easiest to follow when they are described in a consistent order. Many reporters use an anatomical sequence for each type of study, so a reader always knows where to look.

Each finding should be described once, in one place. Repeating the same observation in different words in different paragraphs confuses readers and makes later corrections harder.

Relevant negatives deserve a place too. If the clinical question asks about a particular problem and it is not present, saying so directly is often more useful than leaving the reader to infer it.

• Follows a consistent, familiar order.
• Describes each finding once.
• Includes negatives that answer the clinical question.
• Keeps description separate from interpretation where possible.

Are laterality, measurements and negations correct?

Laterality, measurements and negations are the three details most worth checking twice, because a single wrong word can reverse the meaning of a sentence.

Check every left, right and bilateral against what you saw. Check that each measurement has units and that the numbers match what you measured. Read every sentence containing no, not or without slowly, because speech recognition can drop or add these short words.

Medicate helps here by highlighting laterality words and numbers in the structured draft that do not appear in your original dictation. It is a prompt to look again, not a guarantee, and the final check is always yours.

• Every left, right and bilateral is correct.
• Every measurement has units and the right value.
• Every negation says what you meant.
• Nothing appears in the draft that you did not dictate.

Does the conclusion answer the clinical question?

The conclusion should answer the question in the indication directly. A reader who reads only the conclusion should come away with the right understanding.

Put the most important point first. If there are several points, order them by importance rather than by anatomy, and keep each one short.

Avoid introducing anything in the conclusion that was not described in the findings. If a point matters enough to conclude on, it should appear in the findings first.

• Answers the clinical question in the first line.
• Orders points by importance.
• Introduces nothing new.
• Is short enough to read at a glance.

Is the wording plain and unambiguous?

Plain wording reduces the chance of misunderstanding. Prefer short sentences, common terms and consistent descriptions of certainty.

Avoid local abbreviations that a referrer outside your department may not know. If your team uses a set of agreed phrases for uncertainty, use them consistently so readers learn what each phrase means.

Finally, read the report as the referrer would. If a sentence makes you pause, it will probably make them pause too.

Medicate structures dictated text; the physician reviews and signs every report. It is not a diagnostic tool.

• Short sentences and common terms.
• No unexplained local abbreviations.
• Consistent phrases for uncertainty.
• Read once from the referrer's point of view.

Frequently asked questions