Ultrasound reports: attitudes of referring clinicians to style and content

My colleague, ultrasonographer Leigh Baldock, presented the findings of a survey she carried out as part of her MSc dissertation. This is what our referrers want from us in our ultrasound reports:

• Clinical details re-stated at the beginning of the report.
• Comments on the technical quality of the examination, especially if the examination is suboptimal.
• Mention all organs that have been examined.
• Measurements of abnormal organs, giving a normal range and the measurement of the corresponding normal organ for those with a bilateral presentation.
• Avoid the use of ultrasound terminology unless it is known that the clinician receiving the report has knowledge of such terminology.
• Relate to the clinical question.
• Include significant incidental findings.
• Include differential diagnoses, but not too many.
• Suggest further steps in the investigation of the patient.
• Give advice on further patient management if the referring clinician is a GP or a medical clinician.
• End with a conclusion.
• Be clear and give a comprehensive description even if the findings are normal.

Also:

• There was no substantial difference between the preferences of GPs, medical and surgical referrers, although surgeons do not appear to value recommendations for further management of patients.
• All groups of clinicians are happy for radiologists/sonographers to arrange follow-up examinations, but examinations should not be cancelled without discussion with the referring clinician.

These findings are similar to those in previous published studies.

Leigh will be leaving us shortly to work in Colchester, and we'll miss her. Good luck, and thanks for everything, Leigh.