Start with the actual clinical question
State the principal symptom, the exact body area and side, and what you are trying to confirm or exclude. “Knee pain” is less useful than a focused description of mechanism, site, duration and suspected structure.
Include what changes the scan
Relevant surgery, implants, trauma, cancer history, neurological signs, previous imaging and other information can affect how a request is approached. Include what is pertinent rather than copying an unrelated full medical history.
Why context matters for reporting
Radiologists interpret images more effectively when they understand the clinical question. Context helps findings be weighed against the presentation and can make the final report more directly useful to the referrer.
Keep the handover structured
- Main complaint and laterality
- Duration or mechanism
- Relevant examination findings
- Specific clinical question
- Relevant surgery/implant history
- Previous imaging when available