Standard Radiology Report Headings

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Administrative Information

  • Imaging facility
  • Referring provider
  • Date of service
  • Time of service

Patient Identification

  • Name
  • Identifier (e.g., medical record number or Social Security Number)
  • Date of birth
  • Gender

Clinical History

  • Medical history
  • Risk factors
  • Allergies, if relevant
  • Reason for exam, including medical necessity

Imaging Technique

  • Time of image acquisition
  • Imaging device
  • Image acquisition parameters, such as device settings, patient positioning, interventions (e.g., Valsalva maneuver)
  • Contrast materials and other medications administered (including name, dose, route, and time of administration)
  • Radiation dose

Comparison

  • Date and type of previous exams reviewed, if applicable

Observations

  • Narrative description or itemization of findings, including measurements, image annotations, and identification of key images

Summary (or Impression)

  • An itemized list of key observations, including any recommendations.

Signature

  • The date and time of electronic signature for each responsible provider, including attestation statement for physicians supervising trainees, if applicable


See also: Proposed Standard Radiology Report Headings