Information content and clarity of radiologists' reports for chest radiography.

RATIONALE AND OBJECTIVES

We systematically characterized the information provided by chest radiography reports on a nationally representative sample of 822 elderly patients hospitalized in 297 acute-care hospitals in five states who had an admission diagnosis of congestive heart failure, acute myocardial infarction, or pneumonia.

METHODS

We studied the content of radiography reports, including mention of the type or adequacy of radiography; the presence or absence of a prior radiograph; comments about bones, the aorta, the mediastinum, and pleura and notation of the laterality of findings; and the presence of diagnosis. Two physicians reviewed each patient's report, and a third assigned the final rating when they disagreed.

RESULTS

Our analysis found wide variation in content of chest radiography reports, extensive variation in terms used to identify the presence or absence of abnormal findings, and a large degree of uncertainty in what was found.

CONCLUSION

With most hospitals introducing new information systems in response to technological advances and the need to generate more formal hospitalwide reports, the time is right to improve the quality of chest radiography reporting.