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Report Writing

Report Writing. Robert Tatum, DC, DACBR Associate Professor Radiology Diagnosis Department Palmer College of Chiropractic. Jean Martin Charcot, 1825-1893 “Disease is very old and nothing about it has changed. It is we who change as we learn to recognize what was formerly imperceptible.”

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Report Writing

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  1. Report Writing Robert Tatum, DC, DACBR Associate Professor Radiology Diagnosis Department Palmer College of Chiropractic

  2. Jean Martin Charcot, 1825-1893 “Disease is very old and nothing about it has changed. It is we who change as we learn to recognize what was formerly imperceptible.” De L’Expectation en Medicine Turn everything into an “Aunt Minnie” whenever possible by looking at films, looking at films, and looking at films

  3. Why do we imaging patients? Provide reliable anatomical, morphological & physiological information to effect treatment Treatment should be better than the natural history of the disease

  4. Parameters depend on what you are looking for

  5. Chiropractic Radiologists Skeletal Radiologists (Medical) Chiropractic Radiology Residents General Medical Radiologists Medical Radiology Residents Medical Clinicians Chiropractic Clinicians Chiropractic Students Medical Students Diagnostic Accuracy in the Interpretation of Abnormal Lumbosacral Radiographs 71 70 62 52 45 31 28 20 6 0 10 20 30 40 50 60 70 80 John AM Taylor DC DACBR et al Spine Vol 20 No 10 1995

  6. Report Writing • part of the patient’s medicolegal record • provides a comparison with previous or later examinations • provides a record if radiographs are lost • resume of contraindications or indications • evaluate radiographs in the proper environment • develop a consistent search pattern

  7. The Reading Room • Should be quiet and darkened without distractions. • Provide enough illuminators so that all films of the region In question can be viewed. This is important so that a three dimensional aspect can be perceived. • Hotlight examination of relatively over-exposed regions is an absolute must. • Remember that ALL areas within the collimated field of the radiograph are to be accounted for.

  8. chest AP T LatT cspine AP L Lat L Viewboxes • have enough to view all the anatomy at onetime • at least two 4 over 4’s • hot light …an absolute necessity

  9. Viewing equip. and resources • View stations • Hot light • Ruler • Magnifying Glass • Textbooks

  10. Image Presentation Chiropractic/Surgical Anatomic

  11. I am so bad

  12. I am so bad

  13. Report Writing • reports should contain the following items heading clinical information *(debatable) findings diagnosis/differential diagnosis/conclusions recommendations signature

  14. Report Writing • every radiographic examination MUST have a radiology report generated • heading: date of exam, date of report, patient information, views • clinical information may help with the clinical/radiological correlation but it is debatable on its use in reports

  15. Report Writing • findings: a description of what you see written in paragraph full sentence format, utilizing the “ABC’S” • impression or diagnosis (DDx) or conclusions listed 1,2,... • recommendation: further diagnostic studies or referral Last paragraph of incidental stuff

  16. Findings • the body of the report • contains a written description of the relevant normal and abnormal findings • using full sentence paragraph format • does not contain diagnoses • usually divided into the “ABCS”; “BCAS”, etc • used as a SEARCH pattern • use a flexible search pattern, particularly of related signs

  17. Findings • A: alignment (C,T, L) • B: bone (C,T, L) • C: cartilage (C,T, L) • S: soft tissues (C, T, L) • Cervical ABC’S • Thoracic ABC’S • Lumbar ABC’S

  18. Findings • Decreased anterior vertebral body height is noted at C-7. • A small osteophyte is noted at the anterior inferior aspect of C-5 and possibly C-4. Slight sclerosis is noted involving the C-7/T-1 posterior joints. There is slight decreased disc height noted at the C4-C-7 levels.

  19. Findings • The cervical lordosis is reduced. Slight anterior weight bearing is noted involving the cervical spine. • The prevertebral soft tissues and the remaining soft tissues are within normal limits. • Incidentally noted is an artifact overlying C-1

  20. Impressions • Compression fracture at C-7. (discuss new, old, unknown age, etc) • Early DDD at C-4 thru C-7 with early posterior joint arthrosis at C-7/T-1. • Cervical hypolordosis • Slight anterior weight bearing

  21. Recommendations • Depends on if you know if it is new, old or unknown • New: An orthopedic consultation is needed. With Specialized imaging as needed. • Unknown: Review old films, history, clinical information and special imaging as needed • Old: Correlate clinically with follow up studies as needed.

  22. Findings • does not have to follow the ABC’S format but may be BCAS, SBAC, etc • try to do clinically relevant stuff first • it is a search pattern to look at the entire film • if the B and the C category are both degenerative/arthritic it is okay to put them together into the same paragraph (eg, osteophyte and decreased disc height at C-5=DDD)

  23. Findings

  24. Related findings of a pathological or disease process can go and probably should go in the same paragraph eg, you might combine a B and a C or a B and A or a B and an S or an S and a B or a BAS, Or a BASC etc etc etc

  25. If related BCAS stuff are combined into a related BCAS type paragraph, then there should be a separate and distinct paragraph for the BCAS NON related stuff e.g., If you do an arthritic related BC paragraph you would still need a separate B and a separate C paragraph for all non related (non arthritic) B and C stuff

  26. DEMANDS X • The clinic wants you to use the BCAS format if possible (based on clinical relevance.) • Bony and cartilage changes usually influence alignment changes BC, B, C, A, S Or B, BC, C, A, S Or BCS, B, C, A, S Or etc

  27. The clinic demands you to use the BCAS format if possible (based on clinical relevance.)

  28. Findings • try to use commonly accepted terminology • do not use “listings” • try to be as descriptive as you can • someone should be able to achieve the diagnosis by just reading your findings • some findings are also a diagnosis • the cervical lordosis is reduced (finding) • cervical hypolordosis (dx)

  29. Impressions • diagnoses or differential diagnoses • listed numerically 1, 2, 3,….. • listed in order of clinical significance • order of significance at times is debatable • cervical hypolordosis vs lumbar curve • short precise statements (dx/ddx) • try to be specific and grade conditions • mild degenerative disc disease at C5, etc

  30. Impressions • sometimes a finding will be repeated as a diagnosis • sometimes you may not be sure of a diagnosis and you would repeat the finding with qualifiers such as suggestive of... or consistent with..., etc (pathologic fx) • last impressions are things that are “incidentally noted” such as ponticle, etc

  31. Impressions

  32. Recommendations • further tests that may be needed to support or clarify a diagnosis • lab studies • specialized imaging • concurrent consultations or referrals • technical comments • do not include chiropractic case management options

  33. Recommendations

  34. Report Writing • spine studies need a single report • extremities and chest need separate reports • reports must be signed by the doctor that generates the report

  35. Report WritingChest • SBCA • Is the technique okay

  36. Report Writing/Chest • if no abnormalities are detected • your report would stress the normal findings • “SBCA” type format….chest example • The mediastium is midline and there is no evidence of cardiomegaly. The costophrenic angles are clear. The lung fields are well aerated and without evidence of mass lesion or infiltrate. Visible infradiaphragmatic soft tissues are unremarkable. The visualized soft tissues of the thorax are within normal limits.

  37. Report Writing/Chest • The bone density is adequate. The osseous structures unremarkable and the visualized joint spaces are within normal limits. • A slight right thoracic curvature is noted. • Conclusions: • 1.No definitive abnormalities of the chest are detected • 2. Slight right thoracic curvature • Or: • 1. No definitive abnormalities of the chest are detected • other than a slight right thoracic curvature • Recommendations:

  38. Anatomical considerations

  39. If everything is normal STRESS the positives Using the “ABCS” type format or “BCAS” Talk about what you should be looking at using the search patterns

  40. 68 year old with unrelenting neck pain and upper extremity numbness Findings, Diagnosis and recommendations?

  41. Chordoma 68 year old with unrelenting neck pain and upper extremity numbness Findings, Diagnosis and recommendations?

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