How Should a Radiology Report Be Structured? A Step-by-Step System for Residents

REPORTING SYSTEMATICS / FOUNDATIONAL GUIDE

A practical approach that separates the image-review sequence, the process of documenting findings, and the impression.

Writing a report is more than describing an image

A radiology report transforms observations made on images into clinically meaningful communication. A good report therefore does more than list “what is seen.” It presents, in a clear order, why the examination was performed, how it was acquired, how the important findings relate to the clinical question, and what the reader may need to do next.

One of the most common problems early in residency is confusing the image-review sequence with the report-writing sequence. Images should be evaluated with a detailed, repeatable checklist; the report, however, should be a shorter, hierarchical document that prioritizes the information the clinician needs. A systematic approach separates these two processes, reducing both omissions and unnecessary repetition.

A six-step framework for every examination

1. Clarify the clinical question. The indication, symptoms, known disease, surgical history, and relevant laboratory data determine the focus of the examination. Recognize inadequate or conflicting clinical information and, when possible, complete the context by reviewing prior reports and electronic records.
2. Verify the correct examination and technique. Confirm the patient, date, modality, anatomic region, side, contrast use, phases, reconstructions, and technical limitations. The technique section briefly records details that affect the reliability of the interpretation.
3. Compare with prior examinations. The comparison should not be documented only as “available” or “none.” When there is a clinically important change, state the date and clearly describe the direction of change.
4. Review the images using a fixed search pattern. Develop your own anatomic or window sequence and preserve the same core sequence in every examination. Add focused passes based on the clinical question, but do not abandon the basic survey.
5. Document findings according to importance and anatomy. Describe positive findings with sufficient morphologic detail. Include clinically relevant negative findings related to the question, but avoid repeating every normal structure in long sentences.
6. Provide decision support in the impression. Summarize the most important findings in priority order, state the likely diagnosis or a focused differential when needed, and write actionable recommendations clearly. The report alone may not be sufficient for critical findings; the institution’s notification process must also be followed.

Core sections of the report

Section names may vary between institutions, but the following components form the backbone of most diagnostic imaging reports:

• Indication / clinical information: States as specifically as possible the question the examination is expected to answer.
• Comparison: Identifies the dates of relevant prior examinations and the scope of comparison.
• Technique: Summarizes the modality, contrast administration, phases, reconstructions, and important technical limitations.
• Findings: Presents observations in an anatomic or problem-oriented order.
• Impression: Communicates the most clinically important message in a concise, prioritized, and actionable form.
• Communication note: Documents whom a critical or unexpected finding was communicated to, when, and by what method, in accordance with institutional policy.

The image-review sequence and report order do not have to be identical

For example, you may review a chest CT by moving between lung, mediastinal, and bone windows and the upper abdominal images. You might then write the report in the order “lungs and airways, pleura, mediastinum and hila, cardiovascular structures, chest wall and bones, upper abdomen.” The important point is for the search pattern to be complete and the report structure to be readable.

A finding directly related to the clinical question should be moved to the first item in the impression even if it appears later in the anatomic sequence. This transforms the report from an image-review log into a clinical communication tool.

Five questions to ask when documenting a finding

• Where is it? State the organ, segment, lobe, side, and relationship to adjacent structures.
• How large is it? Use a clinically meaningful measurement and a reproducible method.
• What does it look like? Selectively describe discriminating features such as attenuation, signal, echogenicity, enhancement, margins, and distribution.
• How important is it? Assess acuity, complications, extent, and relationship to the clinical question.
• What has changed since before? Use explicit change language such as stable, new, increased, decreased, or improved.

How should the impression be written?

The impression is not a copy of the findings. The reader should be able to understand the report’s main message by reading the impression first. The most important and urgent finding should come first, with lower-priority secondary findings in subsequent items. When uncertainty exists, state its degree clearly and avoid unwarranted certainty or long differential lists that dilute the message.

When a recommendation is made, its purpose, method, and, when possible, timing should be clear. Recommendations should also be appropriate for the patient’s age, risk factors, prior examinations, and relevant guidelines. Automatically recommending follow-up for every incidental finding may reduce the clinical value of the report.

General report template framework

The following text is not a ready-to-use report; it is a framework that can be adapted to each modality:

Common reporting mistakes made by residents

• Completing a standard template without reading the clinical question.
• Calling a structure normal when it was not adequately imaged.
• Documenting an important finding in the findings section but omitting it from the impression.
• Stating that a prior examination was “compared” without describing the change.
• Changing the measurement method or plane at each follow-up.
• Using excessively long, non-directive differential lists to conceal uncertainty.
• Leaving a critical finding only in the report and overlooking the need for direct communication.

Brief checklist

Before signing the report, ask five questions: Did I answer the clinical question? Are the important findings prioritized in the impression? Did I clearly state technical limitations? Did I describe meaningful change from prior examinations? Did I complete the additional communication required for a critical finding?

A sound reporting system becomes automatic over time. This does not mean thinking less; it means redirecting cognitive energy from repetitive formatting decisions to clinical interpretation.

Sources

1. ACR Practice Parameter for Communication of Diagnostic Imaging Findings (Revised 2025) — Core report components, the impression section, and principles for nonroutine communication. Source (opens in a new tab)
2. RSNA RadReport Reporting Templates — A resource for standardized, consistent, and comprehensive reporting templates. Source (opens in a new tab)
3. ESR paper on structured reporting in radiology—update 2023 — Current framework and implementation principles for structured reporting. Source (opens in a new tab)
4. Structured reporting in radiology: a systematic review — A systematic assessment of the evidence on structured reporting. Source (opens in a new tab)