Dictating- Tips for the Radiology Resident
Dictation is a topic that is rarely touched upon in radiology but is extraordinarily important. In a radiologist’s 30-year career, he/she may dictate over 360,000 reports (assuming 12,000 cases per year for 30 years). In today’s world, it is mostly the dictation that spurs clinicians to act on their patients. Out of 100 cases, only a few are acted upon due to other circumstances such as conversations with a radiologist or by interdisciplinary conferences. These are the exception rather than the rule. Just like a manufacturing company that creates automobiles, dictations are the end product of the radiologist’s service. After all is said and done, it is all that is left in the medical record after we are gone.
It is true that there is a “steep learning curve” for the radiology resident, meaning that there is a rapid incorporation of the techniques of dictation. Much is learned after the initial year of training. But it is only after years and years of experience that the dictation is fine-tuned to the point that the dictation has its maximum utility for physicians.
What are the differences between a radiology resident/newly minted radiologist and a seasoned radiology attending’s dictations? Well, certainly there are always exceptions to every rule. But for the most part, when you look at the resident or new radiologist’s dictations, you see a conclusion that is more verbose and a comments section that contains more impertinent findings. And, that perfectly makes sense because new physicians are putting their feelers out to get a sense of what is truly important for the clinician. Most seasoned radiologists already know this information innately from years of practice.
For residents, it is assumed that they will know how to dictate appropriately after a short period of time and that a radiology resident will just learn to dictate by osmosis. But, it is helpful for the resident to have some guidelines to make the transition easier. So, first I am going to discuss a little about templates for dictating. Then, I will give you some guidelines for each part of the dictation: the history, the technique section, comparisons, comments, and the impression. And finally, I will talk about the use of structured and prose dictations.
When I was a resident just starting out, I remember we had a booklet of templates for all sorts of commonly used dictation types for residents. We would carry around this book during our first days of dictation and would dictate the information to the secretaries upstairs. Today most institutions use dictation/voice recognition software, but the template concept is similar. In fact, it is easier than ever to gather templates from other radiologists to be used for dictation when you are starting out. However, this sometimes complicates things because you may have many different types of templates to choose from for the same type of dictation. My recommendation is to find the best template for a given type of study and to stick to this one type of template when you are starting out. Sure, there will be radiology attendings that insist you use their templates for a given report. That is fine. You should certainly abide by your attending’s wishes because in the end, it is his/her report. Overall, just try to be consistent. The more you use a given template, the more likely you will be to remember all the items that you need to include in a dictation.
Even as a seasoned attending, templates are still extremely useful. Why? They save time and I typically still use them as a checklist to make sure I have looked at all the different organs and physiological systems within the study.
But there are definite pitfalls to using a template. Be very wary… The biggest problem: you may forget to take out the pertinent findings embedded in the template. I’ve seen many reports go out with something like the following statement in the comments section: The kidneys are normal because it is the embedded information in the template. However, when you look at the beginning of the comments section and the impression, they say there is a cystic mass in the kidney. These inconsistencies not only confound the clinician, leading to phone calls but also can be medically and legally ambiguous and potentially dangerous. So always make sure to check your work twice before the dictation is signed off/completed.
What needs to be placed in the history has significantly changed over time. When I first began my radiology residency, histories were initially expected to be a one or two-word blurb about the patient’s condition. Now, with all the new regulations, accreditation bodies, and ICD-10 codes, the histories need to be longer in order to be fully reimbursed for a study. In fact, our billing managers recommend putting as much relevant data as possible in the history in order to ensure that the study is fully reimbursed. One example: When I first started it was frowned upon to put the age of the patient in the dictation history. Now, if I don’t put the age of the patient in my cardiac nuclear medicine dictations, the reports cannot be sent to the accreditation body, for our hospital nuclear medicine department to continue accreditation. So, try to put in as much relevant/appropriate data as possible in the history to ensure the study is fully reimbursed and can be used appropriately. In addition, more history can also sometimes be more helpful for the clinician and can assist in formulating an appropriate conclusion to the clinical question.
It is also very important to put relevant information from prior studies in this section. Often times, residents will put this information in the body of the report. It really is not the place for the history. You can refer to the history from the body, but keeping the history in the body of the report can confound the clinician as to which data is from the current report.
The technique section is the stepchild of the dictated report. It is often times ignored by the clinician and the radiologist reading the dictation. But on occasion, it comes in very handy and should be reported accurately by the dictating physician. For instance, you may say there is a 5mm axial slice thickness on CT scan. If it happens to be you didn’t see a pulmonary nodule on that study and the next study has a slice thickness of 2 mm, it may be that the pulmonary nodule was really present on the prior study but was not visualized because of the differences in technique. If this data is not correct, it can confound the clinician, the radiologist, or the report. So do not ignore this section and be very diligent with dictating the technique accurately.
Also, don’t assume that the template technique is always correct. Many times residents and attendings alike will perform a fantastic dictation and then I look back at the technique section. It is totally wrong. The standard technique template format should have been changed. This error happens more often than physicians realize. Make sure to pay attention!
There is some variability in the placement of this section. I tend to state comparison is made to the previous study dated blank at the beginning of the comments section. Others will make this into a distinct section. Regardless, it will make your comments and impression much easier because the reader will always know which study you are referring to for comparison when you state something is worse, better or improved.
The comments section is the place where the radiologist can “go to town”. Here is the place where all the pertinent negatives and positives belong. Be detailed and specific, especially as a radiology resident. Describe the findings well. Make sure to put in locations, size, morphology, density, and so on. If you see an important finding, it is also a good idea to put in the slice number in the dictation. I have found over the years, it makes it much easier for the attending radiologist to find the abnormality that you are reporting, especially in the case it is subtle and may be hard to find.
One of the issues that confound the novice: should you put the differential in the comments section or only in the impression section? I recommend stating the relevant findings in the comments section and then giving the expanded differential in the comments section based on the relevant findings. You can also state the reasons why you think your final diagnosis is what it is. That same information can be honed and tightened in the impression section later.
Again, be careful with using templates. Many times we will see inconsistencies in the report because standard template statements are left in the dictation. Make sure to erase the standard statements if you make a finding that is different from the standard normal template. Be very careful. Remember the report is a legal document and can be used against you in a court of law!!!
The impression is the standard bearer and the central representation of the quality of the report. It is the place that should contain the information that is most pertinent to the clinical question. For instance, if the question is abdominal pain, the answer should be placed concisely in this section. Always think of the impression as the answer to the reason for the study and your impressions will always be relevant and useful to the clinician ordering the study.
In addition, it is the most widely read part of the report. I like to say that the impression is for the clinician. The rest of the report is for the radiologist. In fact, many times the only part of the report that will be read by the referring doctor is the impression. So, make sure to spend the most time on this section. Check this part over many times to make sure what you are saying makes sense and is concise and relevant. Also, make sure to put your conclusions in this section of the dictation and anything that you think the physician will need to know such as management or follow-up.
Don’t use technical jargon in this part of the report. The bane of the radiologist existence is getting phone calls for unimportant questions about technical terms within your dictation. It wastes lots of time and energy. I can assure you if you put terms in your report in this section that a clinician does not understand, you will get way too many unnecessary phone calls!!!
The impression should contain the most relevant conclusions in your dictation. So, for instance, if you describe the following in your comments section: Within the liver, there is a hypervascular well-circumscribed mass in segment VI measuring 2.5 x 3.0 cm on image #51 with some peripheral nodular enhancement. Delayed imaging does not show typical centripetal filling. The differential includes most likely atypical hemangioma. Other etiologies such as a hepatic adenoma or hypervascular metastatic lesion are within the differential diagnosis but are less likely. MRI is recommended for further characterization. Then the impression can say something like Hypervascular segment VI hepatic mass. Consider most likely hepatic hemangioma. Correlate with abdominal MRI for further characterization. If you notice, the most likely conclusion and the recommendation for further study is placed in the impression section. The other information can be left in the body of the report for further reading if necessary. This way the clinician knows what is most likely and what they should do next without the excess verbiage to potentially confuse the clinician.
What terms are most frowned upon in the impression?
Avoid the usage of cannot be excluded. This statement is usually unhelpful to the physician and does not provide any additional information to the reader. The sun can swallow the earth in the next hour. This cannot be excluded!!!! This statement will inflict the ire of the clinician and will lead to additional unnecessary workup because now the clinician has to workup a very unlikely possibility. However, there is one condition for which I may use this term. In the setting of a positive pregnancy test and a negative pelvic ultrasound, I may say ectopic pregnancy cannot be excluded because I always want the clinician to follow the patient for an ectopic pregnancy with blood work/B-HCG levels regardless of the findings in my dictation. But that is the exception and not the rule!!!
Also, do not use the statement clinical correlation is recommended. Our job as radiologists is to correlate the radiological findings with the clinical findings. It is considered to be a lazy unhelpful statement in all situations. Don’t make the radiologist look bad!!!
There are other terms that you will find that may irk some radiologists. Others may not care as much. I remember one attending who hated the use of the phrase lung zone and the use of the word infiltrates on a chest film. To this day, I do not use these phrases in my dictation because I do not think they are specific. However, I often come across these phrases in other radiologist’s reports. So, you still need to abide by the quirks and specificities of individual radiology attendings. In the end, it is their name at the end of the report!!!
Structured reporting dictations vs. prose dictations
To start, structured reporting is basically a report itemizing the different findings in list form. Usually, it is organ based and may be a fill in the blank or a menu choice of items that the radiologist needs to pick. Using structured reporting vs. prose dictation styles is an area of controversy. Newly minted radiologists will more often apply the rules of structured reporting dictations and seasoned radiologists tend to use a more flexible prose style. But, there is a significant cross-pollination of both styles at all points in the career of radiologists. There is a great article from Radiology called Structured Reporting: Patient Care Enhancement or Productivity Nightmare. (1) I highly recommend you go to this URL if you are interested in learning the advantages and disadvantages of each style of dictation. However, I will summarize by saying that the key to a thorough and understandable dictation regardless of the style is to remember to adopt your own mental checklist and stick to the same program each time you make a dictation. You may adopt either style, as both can be appropriate. Some departments, however, may have standardized dictations and may require the use of either of these styles. So, you need to abide by the rules of your department!
Learning the basic mechanics of dictation is a rapid process. However, learning to dictate reports that are concise, relevant, and useful for the clinician takes the four years of residency and beyond to really hone your skills. I hope the guidelines above make your transition to a more professional dictation style a bit quicker and easier!