Nuclear Medicine Interpretation Report (General)

Patient: [Patient name], [MRN], [DOB]

Exam: [Exam name and protocol]

Date of Study: [Study date]

Interpreting Physician: [Interpreting physician name and credentials]

Indication

[Clinical indication and pertinent history] (Write 1–3 sentences stating the clinical question and relevant history impacting interpretation, including prior diagnoses, therapies, and key labs when applicable such as PSA, glucose, or thyroglobulin.)

Comparison: [Prior relevant studies with modality and date / None available]

Radiopharmaceutical and Technique

Radiopharmaceutical: [Tracer name], [Administered activity in MBq and mCi], [Route], [Injection site] (If any element cannot be confirmed, state "not documented" rather than omitting.)

Timing: [Uptake time or time from injection to imaging]

Acquisition: [planar / SPECT / SPECT-CT / PET / PET-CT], [Anatomic coverage]

CT Component: [Low-dose for attenuation correction and localization / Diagnostic-quality], [Contrast: none / IV / oral] (Omit this field if no CT performed.)

Study Quality: [Technical limitations such as motion, infiltration, or artifacts / No significant technical limitations]

Findings

[Findings organized by anatomic region or clinical problem] (Address the clinical question first. For each abnormality, document location with laterality, uptake pattern and intensity, CT correlation when applicable, and change from prior if available. Include pertinent negatives relevant to the indication. Include quantitative metrics only when clinically validated for the study type. Briefly note relevant incidental findings. If entirely normal, state "No abnormal radiotracer uptake to suggest [indication-relevant pathology].")

Impression

1. [Primary conclusion addressing the clinical question] (Use standardized language such as "consistent with," "suspicious for," or "indeterminate.")
2. [Secondary relevant findings] (Include only if present.)
3. [Recommendations for additional imaging, lab correlation, or follow-up] (Include only when clinically indicated; specify timeframe if appropriate.)

(Do not introduce findings not described above. Ensure laterality consistency between Findings and Impression.)

Critical Results Communication

(Include this section only if urgent or actionable findings were communicated; otherwise omit entirely.)

Finding: [Critical finding communicated]

Recipient: [Name], [Role]

Method: [Phone / Secure message / In-person]

Date/Time: [Date and time of communication]

Confirmation: [Confirmation of understanding obtained / Unable to reach—attempts and escalation documented]