A Patient's Guide to Understanding Radiology Reports

Radiology reports can feel like they’re written in another language, but once you break down the terms and structure, you’ll realize they’re not as intimidating as they seem. This guide will help you understand the components of radiology reports, the terminology used, and the steps you should take to make the most of the information.

What is a Radiology Report?

A radiology report is the written results of your medical imaging test. It contains essential information, such as the patient’s name and date of birth, the reason for imaging, the results, and the name of the radiologist interpreting the results.

Most radiology reports follow a similar format, although the format may differ between radiology departments and imaging clinics.

Why Understanding Your Radiology Report Matters

While radiology reports are intended to be read by medical professionals, understanding your radiology report helps you better manage your healthcare and communicate with your doctor. A thorough understanding of your test results can help you ask important questions, for example, and may give you more confidence in your treatment plan.

Breaking Down Key Sections of a Radiology Report

The format of radiology reports can vary between institutions, as some may add sections for detailed descriptions while others provide only the essential findings. Despite these differences, all radiology reports include certain common elements. Patients who focus on learning these common elements can understand the basic results of most radiology reports.

Indication and the Reason for Your Imaging Test

The “Clinical Indication” is why you have a medical imaging test. It helps the ordering physician communicate with the radiologist and helps the radiologist focus on a specific clinical question. Common indications include:

• Lower back pain
• Assessment of abdominal mass
• Evaluation of a suspected fracture

This section usually includes the patient’s name, gender, and age.

Technique Used for the Imaging Process

Radiologists use a wide variety of imaging machines and imaging techniques to give doctors accurate information. Reporting the techniques used can provide the ordering provider with special insight into the results.

Key elements of the Technique section include:

Imaging Modality – describes the machines (modalities) used to create images; modalities include x-ray, CT, magnetic resonance imaging (MRI), ultrasound, bone densitometry (DEXA), or 3D digital mammography

Imaging Protocol – provides details about the images acquired during the study; this section may describe the thickness of a slice in a CT scan, for example

Equipment – the radiologist describes the imaging equipment used, such as the model, manufacturer, and any technical specifications relevant to the patient’s case

Contrast Administration – some imaging studies use a contrast agent to make specific parts of the body easier to see; this section describes the type of contrast, such as iodinated contrast or gadolinium-based contrast), the route of administration, such as intravenous (IV), oral, or injected into a joint (intra-articular), and the timing of the contrast injection

Limitations – certain factors can affect or “limit” the quality or interpretation of the images; these factors could include, but are not limited to, a patient who moves around, is obese, or has trouble holding their breath

An example of the Technique section:

• Multiplanar multisequence MR imaging was performed of the brain and IACs with and without contrast.

Comparison with Previous Results for Accuracy

Doctors frequently order repeat imaging to monitor their patients’ conditions. When possible, the radiologist compares the results of an imaging test with any previous imaging the patient has undergone. The information in this field helps doctors diagnose problems, evaluate patients’ responses to treatment, and identify any changes.

Radiology Report Example:

• Comparison made with previous cervical spine MRI dated October 30, 2024

Findings and Key Observations in the Report

The Findings section of radiology provides a detailed description of the patient’s anatomy, including any abnormalities and their significance. The Findings section usually includes:

Anatomic Description – describes the specific organs, tissues, structures, or regions of interest relevant to the patient’s condition

Abnormal Findings – describes any abnormalities, variations, or descriptions of what the radiologists find (pathologies) in detail, including the location, size, shape, density, or other important features

Radiology Report Example:

The cervical cord appears normal in its size and signal characteristics.

Impression and Recommendations from the Radiologist

This section contains the radiologist’s interpretation and summary of their findings. It is usually the final part of the report, and often contains the following fields:

• Summary of findings
• Diagnosis – in some cases, the diagnosis is clear; the radiologists may list a diagnosis in the Impression section
• Differential diagnosis – in some cases, the diagnosis is uncertain or there are multiple explanations for the findings; in these cases, the radiologist may provide a list of possible diagnoses in the Impression section

Common Terminology Found in Radiology Reports

Radiologists and doctors use special terminology to communicate. While there are hundreds of medical terms used in radiology, here are some of the most common:

• Anterior – front view
• Posterior – back view
• Lateral view – from the side
• Oblique view – diagonal view
• Supine – lying face up
• Prone – lying face down
• Fracture – broken bone
• Non-displaced fracture – broken bone in which the two pieces of bone stay in place and do not move very far apart
• Avulsion fracture – a type of bone fracture in which a bone fragment tears away from the larger bone mass
• Artifact – something that shows up on an X-ray that isn’t part of the human body; often caused by patient movement during imaging
• Acute – a new injury or illness
• Chronic – an injury or illness that lasts 3 months or longer
• Contrast – a substance that makes organs show up better on an x-ray; may be in IV fluid
• Barium contrast – a chalky substance that some patients drink to coat the inside of their organs so that they show up better on an X-ray
• Densitometry – a method of determining the density of bones; helps doctors diagnose osteoporosis
• Baseline – initial images that the radiologist may use for comparison later
• Pneumothorax – also known as a collapsed lung, a pneumothorax is a condition in which air builds up in the pleural space between the lung and the chest wall
• Plural effusion – excess fluid in the pleural space
• Pericardial effusion – excess fluid in the pericardial sac that surrounds the heart
• Lesion – an area of abnormal or damaged tissue
• Mass – a lump
• Pneumonia – fluid in the lungs
• Cardiomyopathy – weakness of the heart muscles

Understanding Terms Like Unremarkable and Incidental Findings

The term “unremarkable” on a radiology report means the radiologist did not observe any abnormal or significant findings in the scanned areas.

An incidental finding is one in which the radiologist finds an abnormality unrelated to the reason a patient has a test.

Steps to Take After Receiving Your Radiology Report

Your radiology report goes to the doctor who ordered it, and your ordering physician will likely be the one to provide you with the results. If your clinic has a Patient Portal, you may be able to log in and view your radiology reports before you meet with your doctor.

Next Steps After an Abnormal Report

The most important step is to discuss your report with your doctor, who can describe the findings in less technical terms. Be sure to ask questions and listen closely to the answers.

How to Discuss Your Report with Your Doctor

Many patients are nervous when they meet with their doctor to discuss their results, and being nervous can prevent patients from gathering all the information they need for a good outcome. Preparing to discuss your report with your doctor can help you make the most of your appointment.

Taking the following steps can help prepare you for your discussion:

• Write down any questions you may have ahead of your appointment; leave enough space to write down the answers
• Look up any unfamiliar terms on the report
• Ask someone to come with you if you are especially nervous

Questions to Ask During a Follow-Up Appointment

Asking your doctor questions is the best way to understand the status of your health. Your questions may vary depending on your condition, but they may include:

• What did my radiology test show?
• What do the results mean for my health?
• What is the next step in my treatment?
• Are there any side effects of this treatment?
• Are there alternative treatment options?
• Do I need to see a surgeon or another specialist?
• How often will I need follow-up tests and appointments?
• What are my risk factors?
• If additional scans are necessary, how can I minimize my radiation exposure?

The Importance of Clinical Correlation in Radiology

Clinical correlation connects an abnormal finding with what’s going on with the patient. The goal of clinical correlation is to narrow down a differential diagnosis to one accurate diagnosis that accounts for all the patient’s signs and symptoms.

When to Request a Second Opinion on Your Imaging Results

A second opinion can be especially helpful when:

• Your diagnosis is unclear
• The results are difficult to interpret
• You have concerns about the findings
• You are considering major treatment options, such as chemotherapy or surgery
• You have a rare condition in which specialized expertise can help
• You feel uneasy about your diagnosis

Second opinions can provide clarity and peace of mind, especially if the findings are complex or uncertain. Teleradiology services allow you to share your images with specialists worldwide for additional insights.

Using Patient Portals to Access Your Reports

Many healthcare providers now offer patient portals, making it easier than ever to access your radiology reports. This convenience allows you to review your test results before meeting with your doctor, giving you time to prepare questions or research unfamiliar terms.

Storing Medical Records for Future Reference

Tips for Organizing Your Medical Records

• Keep digital and paper copies of your imaging reports and scans.
• Use a filing system organized by date and type of imaging (e.g., X-ray, CT, MRI).
• Consider online storage services for easy access and sharing with healthcare providers.

Tracking Changes with Comparison Reports

Maintaining a chronological record of your imaging tests allows doctors to spot trends and track how a condition responds to treatment over time.

How to Prepare for Follow-Up Tests and Imaging Studies

• Preparing for follow-up imaging may involve:
• Fasting or avoiding certain medications if required.
• Wearing comfortable, metal-free clothing.
• Review the instructions provided by your imaging center to ensure accurate results.

When to Seek Additional Imaging or Monitoring

You might need additional imaging if:

• Your symptoms persist or worsen despite treatment.
• Your initial imaging was inconclusive.
• Your doctor wants to monitor a condition over time.

Clarifying Medical Jargon and Getting Answers

Radiology reports are filled with medical jargon, but you don’t have to decipher them alone. Your doctor is your best resource for breaking down the terms and connecting the dots between the findings and your health.