Foot/Ankle Radiograph Interpretation Report

Patient: [Patient name / MRN / DOB]

Exam: [Study name with laterality]

Accession: [Accession number]

Exam Date/Time: [Date and time]

Facility: [Facility name]

Ordering Clinician: [Ordering clinician name]

Interpreting Clinician: [Interpreting clinician name, credentials]

Clinical Indication

[Clinical indication] (Summarize reason for imaging in 1–3 sentences, prioritizing laterality, mechanism, and timing for trauma; include relevant risk factors when provided. If not provided, state: "Indication: not provided on requisition.")

Comparison

[Prior studies by modality, laterality, and date] (If none available, state "None available." If outside images were reviewed without an imported report, note that.)

Technique

[Body part, laterality, number and type of views]; [weight-bearing / non–weight-bearing / weight-bearing status not documented]. [Limitations if present] (Only mention limitations such as cast obscuration or motion artifact if they materially affect diagnostic confidence.)

Findings

(Begin with laterality. Use structured statements covering alignment, osseous structures, joints, and soft tissues. Include pertinent negatives that address the clinical question. Avoid definitive statements about structures poorly assessed on radiographs such as ligaments or tendons.)

[Right / Left / Bilateral] [ankle / foot]:

• Alignment: [Alignment assessment relevant to clinical question]
• Osseous structures: [Fracture or lesion findings with location, morphology, and severity as applicable]
• Joints: [Joint space, congruity, and degenerative or inflammatory changes]
• Soft tissues: [Soft tissue swelling, effusion, calcifications, or foreign bodies]
• Hardware: [Position, integrity, and periprosthetic findings] (Include only if hardware is present.)

(If bilateral or if both foot and ankle are imaged, repeat for each side/region.)

Impression

1. [Primary conclusion addressing clinical question] (Use calibrated uncertainty such as "findings suspicious for" or "cannot exclude" when appropriate.)
2. [Secondary finding or pertinent negative, if applicable]
3. [Recommendation for additional imaging or follow-up, if clinically indicated]

Communication: [Date/time, method, recipient, and summary of findings communicated] (Include only if direct communication of critical or unexpected findings occurred; otherwise omit this line.)

Electronic Signature: [Interpreting clinician name, credentials, date/time]