Diagnostic Radiology Interpretation Report (General)

Study Information

Patient: [Patient name and second identifier (DOB or MRN)]

Study: [Modality, body part, laterality, accession number]

Date/Time: [Study date and time]

Ordering Provider: [Ordering provider name and service]

Status: [Final / Preliminary]

Clinical History

[Reason for exam and clinical question] (Use one to three concise lines. Include pertinent context affecting interpretation only if provided, such as recent procedures, known malignancy, trauma, or relevant symptoms. If history is absent or inadequate, explicitly state: "Clinical history not provided" or "Limited clinical history provided.")

Comparison

[Most relevant prior study/studies with dates] (Provide a single line. If comparison is limited to report only, note this. If no priors are available, state: "None" or "No prior studies available for comparison.")

Technique

[Procedure description and protocol elements relevant to interpretation] (Include contrast details: agent, route, and dose if documented. Note any study limitations affecting diagnostic quality such as motion, artifact, incomplete coverage, or body habitus. If technique details are unavailable, state: "Technique details not available.")

Findings

[Descriptive observations organized by anatomic region or clinical problem as appropriate to the study] (Lead with the primary region of interest and clinically important abnormalities. For each finding, include location, laterality, size with units, relevant imaging characteristics, and interval change versus priors when applicable. State relevant negatives that directly answer the clinical question. Note incidental findings, prioritizing those potentially requiring follow-up. Avoid exhaustive normal checklists.)

Impression

1. [Direct answer to the clinical question] (State normal/negative if the study is unremarkable.)
2. [Principal diagnosis/finding in descending order of clinical importance]
3. [Key interval changes versus prior] (Include only if applicable.)
4. [Actionable incidental finding(s)] (Include only if present.)
5. [Recommendations with specific what/when/how/why] (Reference relevant guidelines if appropriate.)

(For uncertain findings, provide a limited ranked differential with level of suspicion. If critical or urgent results were communicated outside routine distribution, document recipient, method, and date/time at the end of the Impression.)

Interpreting Radiologist: [Name, credentials, finalization timestamp]

(Never leave Findings or Impression blank. If the examination is unremarkable, include appropriate normal/negative statements that address the clinical question.)