Expressing levels of diagnostic certainty is an integral component of day-to-day clinical practice for radiologists. At the extreme ends of the spectrum of diagnostic certainty are the absolute presence (e.g. “displaced fracture of the right femoral neck”) and the absolute absence (e.g. “no pneumothorax”) of a specific finding. In between these extremes lie a spectrum of possibilities of diagnostic certainty that can be expressed using a wide variety of terms. Traditionally, the phrasing of the level of diagnostic certainty is left to the discretion of...

The standardized certainty lexiconencourages the radiologist to apply one of the followingphrases to express his/her level of certainty for a specific finding: "Consistent with" >90%; "Suspicious for/Probable" ~75%; "Possible " ~50%; "Less likely" ~25%; "Unlikely" <10%. The lexicon was implemented in 2009 and we assumed a two-year preparation- and a two-year settling-in-phase, respectively. Thus, we defined 2007 (n=396)as the control-period and 2011 (n=213)as the study-period, respectively. The prospectively drafted routine MRI reports were retrospectively reviewed and the radiologists level of diagnostic certainty for the presence...

Before the implementation of the certainty lexicon, the reporting radiologists used 49 different termsto express their levels of diagnostic certainty.In order toallow reasonable analysis, these expressions werecondensed to 20 groups (Figure 1). After implementation of the lexicon,the readers adhered to thecertainty lexicon in 85% of the cases. In 15%, however, the radiologists solely described the tumor’s relation to the prostatic capsule without explicetly usinga lexicon term. The level of diagnostoc certaintycorrelated tothe prevalence of ECE on whole-mount histopathology (Figure 2). The diagnostic accuracy of the...

Astandardized certainty lexicon substantially reduces the number of expressions used by radiologists to express their level of certainty in routine clinical reports. The use of a certainty lexicon can therefore improve the communication between the radiologist and the referring physician. The lexicon also provides clinicians with reliable information which can support their clinical decisions.

1. Bastuji-Garin S, Schaeffer A, Wolkenstein P, Godeau B, Carville C, Durand-Zaleski I, et al. Pulmonary embolism; lung scanning interpretation: about words. Chest. 1998;114(6):1551-5. 2. Khorasani R, Bates DW, Teeger S, Rothschild JM, Adams DF, Seltzer SE. Is terminology used effectively to convey diagnostic certainty in radiology reports? Academic radiology. 2003;10(6):685-8.