RADIOLOGY—REVIEW ARTICLE Evidence-based guideline for the written radiology report: Methods, recommendations and implementation challenges Stacy K Goergen, 2,3 Felicity J Pool, 1 Tari J Turner, 4 Jane E Grimm, 11 Mark N Appleyard, 14 Carmel Crock, 7 Michael C Fahey, 5 Michael F Fay, 15 Nicholas J Ferris, 8 Susan M Liew, 9 Richard D Perry, 12 Ann Revell, 16 Grant M Russell, 6 Shih-chang SC Wang 13 and Christian Wriedt 10 1 National University Hospital, Singapore; and 2 Department of Diagnostic Imaging, Southern Health, 3 Southern Clinical School, 4 School of Population Health and Preventive Medicine, 5 Department of Paediatrics, 6 General Practice Research, School of Primary Health Care, Monash University, 7 Emergency Department, Royal Victorian Eye and Ear Hospital, 8 Monash Biomedical Imaging, 9 Orthopaedic Surgery, The Alfred, 10 IMED-MIA, Melbourne, Victoria, and 11 Quality and Safety, The Royal Australian and New Zealand College of Radiologists, 12 PRP Diagnostic Imaging, 13 Diagnostic Radiology, University of Sydney, Sydney, New South Wales, and 14 Department of Gastroenterology and Hepatology, 15 Cancer Care, Radiation Oncology, Royal Brisbane and Women’s Hospital, Brisbane, Queensland, and 16 Breast Cancer Network Australia, Perth Western Australia, Australia SK Goergen MBBS, FRANZCR, MclinEpi; FJ Pool BE, MBChB, FRANZCR; TJ Turner PhD, MBus, BSci(Biomed); JE Grimm BApSc (Physio); MN Appleyard MD, FRACP, MRCP, MBBS, BSc; C Crock MBBS, FACEM, BLitt; MC Fahey MBBS (Hons), PhD, FRACP; MF Fay MBChB, FRACP, FRANZCR; NJ Ferris MBBS (Hons), M.Med., FRANZCR; SM Liew MBBS (Hons), FRACS (orth); RD Perry MBBS (Hons), FRANZCR; A Revell; GM Russell MBBS, FRACGP, MFM, PhD; SSC Wang BSc(Med), MBBS, FRANZCR, FAMS; C Wriedt MBBS, DMRD, FRCR, DDU, FRANZCR. Correspondence Dr Stacy K Goergen, Diagnostic Imaging, Monash Medical Centre, Southern Clinical School, Monash University, c/- RANZCR, Level 9, 51 Druitt Street, Sydney, NSW 2000, Australia. Email: Stacy.Goergen@southernhealth.org.au Conflict of interest: None of the authors declare any competing interests. Submitted 8 August 2012; accepted 28 August 2012. doi:10.1111/1754-9485.12014 Summary The written radiology report is the dominant method by which radiologists communicate the results of diagnostic and interventional imaging proce- dures. It has an important impact on decisions about further investigation and management. Its form and content can be influential in reducing harm to patients and mitigating risk for practitioners but varies markedly with little standardisation in practice. Until now, the Royal Australian and New Zealand College of Radiologists has not had a guideline for the written report. International guidelines on this subject are not evidence based and lack description of development methods. The current guideline seeks to improve the quality of the written report by providing evidence-based rec- ommendations for good practice. The following attributes of the report are addressed by recommendations: 1 Content • Clinical information available to the radiologist at the time the report was created • Technical details of the procedure • Examination quality and limitations • Findings (both normal and abnormal) • Comparison with previous studies • Pathophysiological diagnosis • Differential diagnoses • Clinical correlation and/or answer to the clinical question • Recommendations, particularly for further imaging and other investigations • Conclusion/opinion/impression 2 Format • Length • Format • Language • Confidence and certainty • Clarity • Readability • Accuracy • Communication of discrepancies between an original verbal or written report and the final report • Proofreading/editing of own and trainee reports Key words: evidenced-based guideline; guideline; radiology; report template; structured reporting. Journal of Medical Imaging and Radiation Oncology •• (2012) ••–•• © 2012 The RANZCR® Journal of Medical Imaging and Radiation Oncology © 2012 The Royal Australian and New Zealand College of Radiologists 1