Standard Radiology Report Headings
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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