Proposed Standard Radiology Report Headings

From RSNA Radiology Reporting Initiative
Revision as of 20:30, 10 January 2011 by Cekahn (talk | contribs) (→‎Procedure)
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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.


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


  • 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 Information

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


  • 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)


  • Date and type of previous exams reviewed, if applicable


  • 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.