Difference between revisions of "Proposed Standard Radiology Report Headings"
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(Created page with 'This page describes the proposed report sections for transformation of radiology report templates into HL7 Clinical Document Architecture (CDA) documents. This list extends the ...') |
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= NON-CLINICAL CONTENT = | = NON-CLINICAL CONTENT = | ||
| + | |||
| + | These report sections contain information typically supplied by the Radiology Information System or Electronic Health Record, and are part of the "header" information of an imaging procedure. | ||
== Administrative Information == | == Administrative Information == | ||
| Line 18: | Line 20: | ||
* Gender | * Gender | ||
| − | == Signature == | + | == Signature / Attestation == |
* The date and time of electronic signature for each responsible provider | * 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 CONTENT = | = CLINICAL CONTENT = | ||
| + | |||
| + | These report sections include information selected or entered by the radiologist. | ||
== Clinical Information == | == Clinical Information == | ||
| − | * Medical history | + | * History |
| + | ** Medical history | ||
| + | ** Social history | ||
| + | ** Family history | ||
| + | ** Surgical history | ||
* Risk factors | * Risk factors | ||
* Allergies, if relevant | * Allergies, if relevant | ||
* Reason for exam, including medical necessity | * Reason for exam, including medical necessity | ||
| + | * Clinical query | ||
== Procedure == | == Procedure == | ||
* Time of image acquisition | * Time of image acquisition | ||
* Imaging device | * Imaging device | ||
| − | * Image acquisition parameters | + | * 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 | * Radiation dose information | ||
| + | * Attestation of physician presence / supervision | ||
| + | * Informed consent | ||
| + | * Time-out (confirm correct patient, procedure, and site) | ||
== Comparison == | == Comparison == | ||
| − | * Date and type of previous exams reviewed | + | * Date and type of previous exams reviewed |
| + | ** Pertinent observations from prior examinations will be described in the Observations section | ||
== Observations == | == Observations == | ||
| Line 47: | Line 65: | ||
** Image annotations | ** Image annotations | ||
** Identification of key images | ** Identification of key images | ||
| − | * | + | ** Previous observations |
| − | * | + | * Complications (including contrast reactions) |
| + | ** Nature of complication | ||
| + | ** Treatment | ||
== Summary (or Impression) == | == Summary (or Impression) == | ||
* An itemized list of key observations, including any recommendations. | * An itemized list of key observations, including any recommendations. | ||
| + | * Assessment | ||
| + | * Plan | ||
| + | |||
| + | == Communication == | ||
| + | * Nature of communication | ||
| + | ** Discrepancy from preliminary interpretation | ||
| + | ** Critical result communication | ||
| + | * Specific findings, if applicable | ||
| + | * Urgency | ||
| + | * Recipient (physician, patient, other) | ||
| + | * Mode of communication (telephone, certified mail, etc.) | ||
| + | * Date and time | ||
| + | == Addendum == | ||
| + | * Textual description of revisions from prior signed document version | ||
= OPEN ISSUES = | = OPEN ISSUES = | ||
| + | |||
| + | * Map report section names to DICOM section names (CID 7001) | ||
| + | * Harmonize with ACC Key Data Elements for Cardiovascular Imaging | ||
| + | * Harmonize with Consolidated Health Story | ||
| + | * Interventional procedures? | ||
Latest revision as of 14:14, 12 January 2011
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
These report sections contain information typically supplied by the Radiology Information System or Electronic Health Record, and are part of the "header" information of an imaging procedure.
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 / Attestation
- 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 CONTENT
These report sections include information selected or entered by the radiologist.
Clinical Information
- History
- Medical history
- Social history
- Family history
- Surgical history
- Risk factors
- Allergies, if relevant
- Reason for exam, including medical necessity
- Clinical query
Procedure
- 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)
Comparison
- Date and type of previous exams reviewed
- Pertinent observations from prior examinations will be described in the Observations section
Observations
- Narrative description or itemization of findings, including:
- Encoded findings
- Measurements
- Image annotations
- Identification of key images
- Previous observations
- Complications (including contrast reactions)
- Nature of complication
- Treatment
Summary (or Impression)
- An itemized list of key observations, including any recommendations.
- Assessment
- Plan
Communication
- Nature of communication
- Discrepancy from preliminary interpretation
- Critical result communication
- Specific findings, if applicable
- Urgency
- Recipient (physician, patient, other)
- Mode of communication (telephone, certified mail, etc.)
- Date and time
Addendum
- Textual description of revisions from prior signed document version
OPEN ISSUES
- Map report section names to DICOM section names (CID 7001)
- Harmonize with ACC Key Data Elements for Cardiovascular Imaging
- Harmonize with Consolidated Health Story
- Interventional procedures?