Difference between revisions of "Standard Radiology Report Headings"
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| Line 11: | Line 11: | ||
* Gender | * Gender | ||
| − | == Clinical | + | == Clinical History == |
* Medical history | * Medical history | ||
* Risk factors | * Risk factors | ||
| Line 17: | Line 17: | ||
* Reason for exam, including medical necessity | * Reason for exam, including medical necessity | ||
| − | == Imaging | + | == Imaging Technique == |
* Time of image acquisition | * Time of image acquisition | ||
* Imaging device | * Imaging device | ||
| Line 30: | Line 30: | ||
* Narrative description or itemization of findings, including measurements, image annotations, and identification of key images | * Narrative description or itemization of findings, including measurements, image annotations, and identification of key images | ||
| − | == Summary or Impression == | + | == Summary (or Impression) == |
* An itemized list of key observations, including any recommendations. | * An itemized list of key observations, including any recommendations. | ||
== Signature == | == Signature == | ||
* The date and time of electronic signature for each responsible provider, including attestation statement for physicians supervising trainees, if applicable | * The date and time of electronic signature for each responsible provider, including attestation statement for physicians supervising trainees, if applicable | ||
Revision as of 18:51, 29 May 2009
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