The wording of diagnostic conclusions. The conclusion of a radiologist is a final stage of radiology. It is in exceptional cases may be reported to your doctor in oral form (in the conditions of emergency radiology, x-ray diagnosis on the operating table during surgery, and so on), but, as a rule, the conclusion must be made in writing to the Protocol as x-ray examinations, which in outpatient conditions can be written on a special form, and in stationary conditions listed directly in the history of the disease.
The Protocol must be clear in a form understandable by the content and consist of three parts.
In the first part should be reflected formal data: name and address of the institution, the number and date of the Protocol, surname, name, patronymic name and age of the patient, studied area (or areas), and so on
The second part is descriptive and should include a concise but comprehensive manner characteristic detected by the radiologist pathological changes, expressed in a commonly understood and accepted in medicine, pathology and pathophysiology of terminology, designations. If along with the research area in which the doctor suspects pathological changes (for example, the stomach), examined other areas (such as the bowel or the chest), the Protocol should be reflected found in them pathological changes or not such.
In the third and final part shall be formulated by the x-ray diagnosis if there are sufficient grounds arising from the second part of the Protocol. In the absence of sufficient data for the production of x-ray diagnosis, the radiologist may be limited to the narrative, providing to the Clinician to use that part of the x-ray data, which may be useful for setting or Refine clinical diagnosis. When a reasonable rational considerations about possible diagnostic options radiologist can lead to a hypothetical form. If there is reason to believe that by some additional researches is possible to achieve significant new data or to do this, it seems reasonable repeated x-ray examination, the radiologist may in the final part to offer recommendations. Often when you study the wording of x-ray diagnosis is possible.
The report shall be signed by a medical radiologist, which produced the study, bearing all the fullness of medical, moral and legal responsibility. Conclusion containing conclusions about the presence of life-threatening or terminal illness should not be issued to the patient at hand, and through appropriate channels, to be forwarded to the doctor. Cm. also examination of a patient, x-Ray examination, Semiotics.