MRI Report

Exam: [exam title with body region and contrast status]

Accession: [accession number]

Study Date/Time: [date and time performed]

Patient: [name]

DOB/Age: [as locally preferred]

MRN: [medical record number]

Facility: [site name]

Interpreting Physician: [name]

Referring Clinician: [name/service]

Report Status: [Preliminary / Final / Addendum]

Clinical Information

[Brief indication, relevant history, and clinical question] (If indication is missing, state "Clinical history: Not provided." Note constraints affecting interpretation only if relevant to findings.)

Comparison

[Prior studies by modality, region, and date] (If multiple priors, list each separated by semicolons. If none, state "Comparison: None available.")

Technique

Multiplanar, multisequence MRI of the [region] performed [without / with / with and without] IV contrast.

• Field strength: [1.5T / 3T] (Include if available.)
• Contrast: [None / agent name, route, and dose] (If administered, note any adverse event. If intended but not given, state reason.)
• [Advanced techniques if performed, e.g., DWI, perfusion, MRA] (Omit if none.)
• [Study quality or limitations] (Include only if affecting diagnostic confidence.)

Findings

(Organize by anatomic region or clinical problem. Use subheadings appropriate to the body region examined. Include relevant negatives that address the clinical question. Incorporate interval change when priors exist.)

[Anatomic region]

[Findings for this region including: location with laterality, morphology, size in mm, signal characteristics on relevant sequences, enhancement pattern if contrast given, ancillary features, and interval change vs. priors] (Reference series/image numbers for complex cases. Distinguish expected postoperative changes from complications. For incidentals, distinguish clinically significant findings from likely benign.)

[Additional region]

[Findings as above] (Add or remove subheadings as appropriate to the exam.)

Impression

1. [Highest-priority conclusion addressing clinical question] (Provide most likely diagnosis or limited differential; use confidence qualifiers when uncertainty matters.)
2. [Additional finding with interpretation] (Include interval change if applicable.)
3. [Indeterminate finding with recommendation] (Include only if follow-up is standard of care; specify modality and timeframe.)

(Limit to 1–5 items. Ensure findings support impression; laterality, dates, measurements, and contrast status must match across sections.)

Communication

(Include only for unexpected time-critical findings requiring nonroutine communication.)

• Finding communicated: [critical/unexpected finding]
• Recipient: [name and role]
• Method: [phone / in-person / secure message]
• Date/Time: [communication timestamp]
• Read-back: [obtained / not required] (If unsuccessful, document attempts and escalation.)

Electronically signed by: [Interpreting physician name and credentials]

Date/Time: [finalization timestamp]