Proposed Standard Radiology Report Headings

This page describes the proposed report sections for transformation of radiology report templates into HL7 Clinical Document Architecture (CDA) documents. This list extends the Report Sections defined at the initial RSNA Reporting Forum.

Please note that the "bullet points" under each heading serve as examples of content, not as an exhaustive list of data subtypes.

NON-CLINICAL CONTENT

These report sections contain information typically supplied by the Radiology Information System or Electronic Health Record, and are part of the "header" information of an imaging procedure.

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

Signature / Attestation

• The date and time of electronic signature for each responsible provider

(Note: Statements regarding supervision of trainees or other professionals are provided in the "Procedure" section.)

CLINICAL CONTENT

These report sections include information selected or entered by the radiologist.

Clinical Information

• History
  • Medical history
  • Social history
  • Family history
  • Surgical history
• Risk factors
• Allergies, if relevant
• Reason for exam, including medical necessity
• Clinical query

Procedure

• Time of image acquisition
• Imaging device
• Image acquisition parameters
  • Device settings
  • Patient positioning
  • Interventions (e.g., Valsalva maneuver)
• Substances administered
  • Name (e.g., Omnipaque-300)
  • Amount, route, time of administration
• Radiation dose information
• Attestation of physician presence / supervision
• Informed consent
• Time-out (confirm correct patient, procedure, and site)

Comparison

• Date and type of previous exams reviewed
  • Pertinent observations from prior examinations will be described in the Observations section

Observations

• Narrative description or itemization of findings, including:
  • Encoded findings
  • Measurements
  • Image annotations
  • Identification of key images
  • Previous observations
• Complications (including contrast reactions)
  • Nature of complication
  • Treatment

Summary (or Impression)

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

Communication

• Nature of communication
  • Discrepancy from preliminary interpretation
  • Critical result communication
• Specific findings, if applicable
• Urgency
• Recipient (physician, patient, other)
• Mode of communication (telephone, certified mail, etc.)
• Date and time

Addendum

• Textual description of revisions from prior signed document version

OPEN ISSUES

• Map report section names to DICOM section names (CID 7001)
• Harmonize with ACC Key Data Elements for Cardiovascular Imaging
• Harmonize with Consolidated Health Story
• Interventional procedures?