correlate and compare



As a report reader, I don’t see the benefit of sub-categorizing prior exams as comparison or correlative. They are all prior exams.  Adding more report section headers detract from the point of section headers, which is to draw the reader’s attention to important information.

I don’t think a separate Comparison section is necessary or warranted. I will expound on that thought in a future post.




more words to say less

“There is no focal infiltrate.”

This statement doesn’t explicitly exclude diffuse or multifocal infiltrate. It’s an example of using more words to say less.

“There is no infiltrate,” excludes focal, multifocal, diffuse, and any other infiltrate.

N.B. Infiltrate is not recommended by the Fleischner Society, and has be replaced by other descriptors. The term opacity, with relevant qualifiers, is preferred.

verbose

“An endotracheal tube is again seen and unchanged with its distal tip approximately 4.2 cm above the level of the carina.”
Can be more concisely written as:
“Stable ET tube about 4 cm above the carina.”
The Flesch-Kinkaid reading grade level on the first sentence is 13.3, but drops to 6.2 on the edited version. That is hyperlucent reporting!
I agree with using incontrovertible abbreviations like “ET tube”, but err on the side of spelling it out. 
I’ve taken to giving only whole and half centimeter increments for ET tubes. Reporting “4 cm” looks cleaner to me than “4.2 cm”. I don’t think I can tell 0.2 cm with any precision, and I’m sure it’s not required. For some reason 4.5 cm or 6.5 cm looks better to me than 4.2 cm or 6.7 cm for example.

stable impressions

For this statement to have meaning, the report reader must know what the chest 
looked like before. If that information is unknown to the reader, they must find out what the prior report said. Or they can read the “Findings” section of the current report to learn what is deemed stable, or skip the reports altogether and do their own image interpretation.