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 and treatment

Summary (or Impression)

An itemized list of key observations, including any recommendations.

Proposed Standard Radiology Report Headings

Contents