Fundus Photography Interpretation Report

Patient: [name, MRN, DOB per local policy]

Date of Service: [date]

Study Type: Fundus photography — [color / red-free / fundus autofluorescence (FAF) / widefield / ultra-widefield / other: [specify]]

Laterality: [OD / OS / OU]

Ordering Clinician: [name, credentials]

Interpreting Clinician: [name, credentials]

Indication

[Brief statement of medical reason and clinical question] (1–2 sentences. Include relevant symptoms, risk conditions, or known diagnoses that affect interpretation. If indication not provided in the order, state: "Indication not provided; interpretation limited to visible findings.")

Image Quality & Technique

• Dilation status: [dilated / not dilated / unknown]
• Views obtained: [views and field of view as applicable]
• OD adequacy: [Gradable / Suboptimal but interpretable / Ungradable] (If not fully adequate, state reason and structures not reliably assessed.)
• OS adequacy: [Gradable / Suboptimal but interpretable / Ungradable] (If not fully adequate, state reason and structures not reliably assessed.)

(Never conclude "normal" for ungradable images.)

Findings

(Organize by eye. Focus on pertinent positives and clinically meaningful negatives for optic nerve/disc, macula, vessels, and retina. Include disease severity/staging when applicable. Note whether periphery was imaged and any limitations.)

OD

[Findings by structure as relevant to indication] (Include comparison to prior photographs if available with date and interval change assessment. If no priors, state: "No prior fundus photographs available for comparison.")

OS

[Findings by structure as relevant to indication] (Include comparison as above.)

(If findings are symmetric and both eyes are adequately imaged, may use a single OU section instead.)

Impression

1. [Eye and primary diagnosis or descriptive conclusion with severity/stage if applicable] (Prioritize by clinical urgency.)
2. [Additional diagnoses or findings by eye, as needed]
3. [Image quality limitation statement, if any images are ungradable or key areas not visualized]

(When uncertainty exists, use phrasing such as "may represent [condition]" and tie uncertainty to specific image limitations.)

Recommendations

[Recommended follow-up, additional testing, clinical correlation, or referral as indicated] (Include safety-net advice if symptoms suggest urgent pathology that photographs cannot exclude. Omit this section entirely if findings are unremarkable and no action is needed.)

[Interpreting clinician signature]

[Credentials]

[Date/time signed]