Standard Radiology Report Headings

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