Proposed Standard Radiology Report Headings

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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 is 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, 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 information

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.


OPEN ISSUES