Bone Scintigraphy Interpretation Report

Exam: [whole-body bone scintigraphy / 3-phase bone scan / bone SPECT/CT / other bone scintigraphy protocol]

Date of Exam: [exam date]

Patient: [patient name]

DOB/Age: [date of birth and/or age]

MRN: [medical record number]

Ordering Clinician: [name and credentials]

Interpreting Physician: [name and credentials]

Clinical Information

Indication: [clinical question, e.g., evaluate for osseous metastases / assess focal pain / evaluate for occult fracture / evaluate for osteomyelitis]

Relevant History: [pertinent oncologic or orthopedic/trauma history relevant to indication] (Include primary malignancy and known metastatic sites; or surgical/hardware/fracture history and pain location. Do not infer cancer type, stage, or treatment history from imaging appearance.)

Comparison: [prior studies with dates] (Only list if images or reports were reviewed; otherwise state "None available.")

Technique

Radiopharmaceutical: [radiotracer, e.g., Tc-99m MDP] | Activity: [administered activity in mCi and/or MBq] (State "not recorded" for any missing elements.)

Injection: [injection site, date/time, extravasation if present] (State "not recorded" if unavailable.)

Imaging: [uptake interval post-injection] | Protocol: [planar whole-body / limited planar / 3-phase / SPECT / SPECT/CT] [region if applicable]

CT Technique: [low-dose localization vs diagnostic; contrast use; dose metrics if recorded] (Include only if SPECT/CT performed.)

Limitations: [motion / incomplete coverage / contamination / attenuation artifact / none—study of diagnostic quality] (Note factors that materially affect interpretation.)

Findings

Image Quality: [diagnostic / limited] (Note expected biodistribution or any confounding distribution affecting interpretation.)

Osseous: [abnormal foci organized by anatomic region] (For each abnormality: location with laterality, uptake pattern and intensity, CT correlate if SPECT/CT, comparison status if prior available, interpretive assessment. Summarize degenerative changes globally. Provide clear negative statement if no suspicious osseous findings.)

Soft Tissue/Extraosseous: [abnormal soft tissue uptake, prominent injection site activity, urinary contamination affecting pelvic evaluation, significant incidental CT findings] (Omit this line entirely if no relevant findings.)

Impression

[Primary conclusion addressing clinical question] (State presence or absence of metastatic disease or other indication-specific outcome with brief supporting pattern.)

[Interval change summary] (Include only if comparison available; state progression, stability, or new/resolved findings.)

[Recommendations] (Include targeted imaging for indeterminate findings as appropriate.)

[Communication of critical findings: recipient, date/time, method] (Include only if urgent communication occurred.)