Residents who are new to on-call reporting may swing between two extremes: describing everything in detail until the main result disappears, or writing so briefly that...
| Quick summary A good on-call report is not necessarily a long report. It belongs to the correct patient, states its technical limitations, answers the clinical question, and clearly highlights the most important result. |
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| Medical safety note This content is intended for the education of radiology residents and trainees. It does not provide patient-specific diagnosis, treatment, or emergency management instructions. Institutional protocols, scope-of-practice limits, and the supervising radiologist's guidance take precedence. |
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Residents who are new to on-call reporting may swing between two extremes: describing everything in detail until the main result disappears, or writing so briefly that uncertainty and important negative findings are omitted. A good report is not defined by its word count, but by whether it gives a safe and understandable answer to the clinical question.
Current RCR reporting standards identify two core goals: the report should prompt appropriate patient care, and the interpretation should be communicated clearly. [1] The ACR likewise considers effective communication a critical component of diagnostic imaging. [2]
Your institution's template may use a different order. What matters is that the reader can find the expected information in the same place in every report.
Read the request before opening the examination and ask yourself, "What decision will this study inform?" If the clinical question is unclear, contact the referring team. Filling gaps by assumption can create an incorrect framework for the report.
Stating only that motion artifact is present may not be enough. Explain which assessment is affected and to what extent. Do not make the examination's diagnostic capability sound weaker or stronger than it is.
| Type / Note | Example wording |
|---|---|
| Weak | Motion artifacts are present. |
| Better | The examination is partially limited by motion artifact; assessment for small peripheral emboli is not reliable. |
| Weak | This is a noncontrast examination. |
| Better | Assessment of vascular structures and solid-organ perfusion is limited by the absence of intravenous contrast. |
These examples illustrate wording only; each sentence must be adapted to the technical features of the actual examination.
A systematic sequence is a memory aid that reduces omissions, especially during fatigue and interruptions. The sequence varies by modality and anatomy, but it is important to follow the same path each time for the same type of examination.
A radiology report does not always contain a definitive diagnosis. Terms expressing uncertainty should not be used randomly. Phrases such as "consistent with," "suggestive of," "probable," "cannot be excluded," and "suspicious for" imply different levels of confidence. Use your institution's shared terminology and make the clinical effect of uncertainty visible in the impression.
| Type / Note | Example wording |
|---|---|
| Vague | Clinical correlation is recommended. |
| More actionable | The findings are nonspecific in isolation; if infection is suspected, they should be interpreted with the clinical and laboratory data. |
| Vague | Malignancy cannot be excluded. |
| More actionable | The imaging features of the lesion are nonspecific. To exclude malignancy, specialty evaluation and appropriate further imaging may be considered in accordance with local protocol. |
When recommending further imaging or consultation, stay within your scope of practice and follow local guidance. Avoid automatic recommendations added to every case.
The impression is not a copy of the findings section. It should summarize the one to three most important messages in order of clinical effect. An urgent finding should appear first; lower-priority incidental findings should be listed separately.
The status of an on-call report varies across training institutions. If a preliminary report will later be reviewed by an attending radiologist, that status should be clear both in the system and in the text. RCR standards emphasize explicitly identifying a report as provisional when a required second opinion has not yet been obtained. [1]
| Labeling a report as preliminary does not remove responsibility. Critical findings must still be communicated promptly, and uncertainty must still be discussed with a senior. |
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☐ Is this the correct patient and examination?
☐ Are laterality, anatomic level, and measurements consistent?
☐ Did I answer the clinical question clearly?
☐ Did I state the technical limitation and its effect?
☐ Do the findings and impression agree?
☐ Are the prior study and date correct?
☐ If critical communication was required, was it completed and documented?
☐ Is there any irrelevant text left from the template?
Shortcut tools such as RadPhrases can speed up repetitive report structures. The safest use is to standardize organization, limitation, comparison, and communication wording rather than automate complete diagnoses. Every inserted statement must be verified by the user. [3]
This content is educational and is not patient-specific medical advice. Every phrase, template, classification result, and recommendation must be verified and adapted by a physician using the complete examination, clinical context, current guidelines, and institutional protocol.
Keep frequently used phrases, report templates, and safety checks accessible inside RadPhrases.
Browse the other checklists, phrase sets, and systematic approaches in this topic.
