Radiology Overread Discrepancy Addendum Note

Date/Time: [system timestamp]

Author: [name, role/credentials]

Encounter: [location/service, encounter date, patient disposition at time of addendum]

Addendum — Radiology Overread Discrepancy (Reference original preliminary source: [interpreter, timestamp, report location].)

Imaging Study Identification

• [Imaging modality and body region, including laterality if applicable]
• [Study date/time]
• [Accession number]
• Preliminary: [interpreter name/role, timestamp, where recorded]
• Final overread: [radiologist name, timestamp, report location]

Discrepancy Summary

Preliminary interpretation indicated [X]; final overread demonstrates [Y].

• [Clinically meaningful delta: new or excluded diagnosis, change in location/severity/extent, or newly identified actionable finding] (Use neutral phrasing; do not duplicate full report.)
• Urgency: [Critical (minutes) / Urgent (hours) / Semi-urgent (days) / Routine]

Communication Log

(Document each communication event on a timestamped line. Omit this section only if no communication beyond the final report is required.)

• [Timestamp] — Clinician: [name, role] | Method: [phone / page / secure message / in-person] | Content: [what changed; action needed; timeframe] | Confirmation: [read-back obtained / explicit acceptance / awaiting response]
• [Timestamp] — Patient: ID verified via [method] | Method: [phone / portal / in-person] | Content: [brief update and recommended action] | Understanding: [verbalized understanding / questions addressed] | Response: [accepted plan / declined / pending]
• [Timestamp] — Attempted contact: [intended recipient] | Method: [call / page / message] | Outcome: [no answer / voicemail left / mailbox full] | Escalation: [who notified / next step / timeframe]
• [Additional entries as needed]

Updated Assessment & Plan

[Updated clinical impression prompted by the overread]

• [Immediate actions if urgent] (e.g., return to ED, call 911) (Include only if applicable.)
• [Time-bounded follow-up: specific test/consult, timeframe, responsible party]
• [Tracking mechanism: referral placed / appointment scheduled / task created / PCP notified]
• [Patient-reported symptom status and tailored return precautions] (Include only if patient contact occurred.)
• [If patient declined: stated reasons, capacity assessment, alternate plan, safety net] (Include only if applicable.)
• [If patient unreachable: symptom status could not be assessed; contingency plan] (Include only if applicable.)

Attestation

[Signature/authentication per EHR mechanism]

(Attribute actions by other team members: "Per phone call by [name], [role]." Document interpreter use if applicable.)