DXA Bone Densitometry Report

Patient: [name, DOB, sex, MRN]
Study Date: [date]
Facility/Accession: [facility and accession/study ID]
Ordering Clinician: [name]
Interpreting Physician: [name, credentials]

Clinical Indication

[Indication for study: screening / diagnostic evaluation / therapy monitoring. Include relevant clinical context if provided: menopausal status, prior fragility fracture, current osteoporosis therapy, high-risk medications, or secondary osteoporosis risk factors. Note height and weight if available.] (Do not infer menopausal status or treatment history. If menopausal or treatment status is not provided and affects scoring, state explicitly that it was not provided.)

Technique

[Examination type: baseline / follow-up. Scanner manufacturer and model. Anatomic sites acquired: PA lumbar spine, hip(s), forearm, and any additional modules such as VFA, TBS, or full-length femur. Technical limitations or artifacts affecting interpretation if present.] (Omit technical limitations if none.)

Comparison: [No prior study available / Compared to prior DXA from [date] at [facility] / Prior study exists but comparison is limited due to non-cross-calibrated scanner or unknown precision data] (If multiple priors exist, specify which is used as baseline.)

Results

(Report BMD in g/cm² to three decimals; T-scores and Z-scores to one decimal. Use T-scores for postmenopausal women and men age 50 and older; use Z-scores for premenopausal women and men under 50. For follow-up studies with valid comparison, report absolute and percent change and whether change is stable, significant increase, or significant decrease per facility LSC. If a site was attempted but uninterpretable, list the site as uninterpretable with the reason.)

Lumbar Spine (PA): [Vertebral levels included and any excluded levels with reason. BMD and appropriate T- or Z-score. For follow-up with valid comparison, include absolute and percent change from prior and whether change exceeds facility LSC.] (Do not report diagnostic classification from a single vertebral body.)

Hip: [Side(s) acquired. Femoral neck and total hip BMD with appropriate T- or Z-scores. For follow-up with valid comparison, include absolute and percent change and whether change is significant per facility LSC.] (For diagnosis with bilateral hips, use the lowest T-score across femoral neck and total hip from either side. For monitoring with bilateral hips, use mean bilateral total hip BMD for trending.)

Forearm: [33% radius of non-dominant forearm with BMD and appropriate T- or Z-score. Note hand dominance. For follow-up with valid comparison, include absolute and percent change and significance per facility LSC.] (Include only if performed.)

Additional Findings: [VFA: vertebral levels visualized, method used, and any fractures by level and grade. TBS: value and category. Full-length femur: pertinent findings.] (Include only if additional modules were performed; omit entirely if none.)

Impression

• [Diagnostic category: Normal / Low bone mass / Osteoporosis for T-score populations; Within expected range for age / Below expected range for age for Z-score populations. Specify site used for classification.]
• [For follow-up with valid comparison: Interval change at each site relative to facility LSC: stable / significant increase / significant decrease.]
• [Key limitations affecting interpretation.] (Include only if present.)
• [FRAX if calculated: tool version, whether BMD was included, 10-year hip fracture probability, 10-year major osteoporotic fracture probability, and positive risk factors used.] (If patient is on osteoporosis therapy, note that FRAX is not validated for treated populations. Include only if explicitly performed.)
• [If Z-score is below expected range for age or bone loss is unexpectedly rapid, recommend evaluation for secondary causes.] (Include only if applicable; do not diagnose secondary causes.)

Facility LSC (95% CI): [Lumbar spine: X%; Total hip: X%; Femoral neck: X%]

Recommendations

[Follow-up DXA interval based on clinical circumstances. If VFA shows equivocal findings or suspicious lesions, recommend appropriate follow-up imaging.] (Defer pharmacologic management recommendations to the managing clinician. Omit recommendations not supported by provided clinical context.)