Independent Interpretation Note (Imaging/Labs)

Date/Time Authored: [date and time]

Author: [name, role, service]

Encounter: [ED / inpatient / outpatient]; [location]

Study

Test: [modality and anatomic target]

Performed: [date/time, or "not available" if unknown]

Indication: [brief clinical question]

Interpretation

Findings:

• [Pertinent positive and negative findings relevant to clinical question] (Include laterality, anatomic location, and severity qualifiers when relevant. Note technique or quality limitations only if they affect reliability. If comparison to prior study was performed and influenced management, include change assessment.)

Impression: [single-line synthesis tied to clinical question] (Use certainty phrases such as "Consistent with...," "Concerning for...," "No evidence of...," or "Indeterminate; cannot exclude..." Note if formal interpretation is pending or if there is clinically relevant concordance/discrepancy with formal read.)

Management Impact

• [Action taken or decision confirmed based on interpretation] (Begin each item with a verb. Include at least one concrete management consequence such as treatment change, consult, additional testing, or disposition decision. If interpretation confirmed existing plan without change, document that.)

Communication

(Include this section only when findings are critical, time-sensitive, or discrepant from formal interpretation; omit entirely otherwise.)

Notified: [name, role]

Method: [phone / in-person / secure message]

Date/Time: [date and time of communication]

Content: [what was communicated]

Confirmation: [confirmation or read-back per policy]

"I personally reviewed the [images / tracing] and this represents my independent interpretation used for clinical management. This is not a formal radiology/cardiology report."