Difference between revisions of "Proposed Standard Radiology Report Headings"

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** Image annotations
 
** Image annotations
 
** Identification of key images
 
** Identification of key images
* Complications
+
* Complications (including contrast reactions)
** including contrast reactions and treatment
+
** Nature of complication
 +
** Treatment
  
 
== Summary (or Impression) ==
 
== Summary (or Impression) ==
 
* An itemized list of key observations, including any recommendations.
 
* An itemized list of key observations, including any recommendations.
 
+
* Assessment
== Addendum ==
+
* Plan
* Textual description of revisions from prior signed document version
+
  
 
== Communication ==
 
== Communication ==
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** Critical result communication
 
** Critical result communication
 
* Urgency
 
* Urgency
* Recipient
+
* Recipient (physician, patient, other)
 +
* Mode of communication (telephone, certified mail, etc.)
 
* Date and time
 
* Date and time
 +
 +
== Addendum ==
 +
* Textual description of revisions from prior signed document version
  
  
 
= OPEN ISSUES =
 
= OPEN ISSUES =

Revision as of 20:37, 10 January 2011

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

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

  • 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

Clinical Information

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

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, if applicable

Observations

  • Narrative description or itemization of findings, including:
    • Encoded findings
    • Measurements
    • Image annotations
    • Identification of key images
  • 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
  • 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