X-ray Report

Report Status: [Final / Preliminary / Addendum]

Patient: [Full name and one additional identifier]

DOB/Age: [Date of birth and/or age]

Sex: [Sex]

Exam: [Specific X-ray exam name with anatomic region and laterality]

Exam Date/Time: [Date and time of acquisition]

Ordering Provider: [Ordering clinician name / not provided] (State "not provided" if missing rather than omitting.)

Interpreting Radiologist: [Radiologist name and credentials]

Clinical History / Indication

[Reason for exam and specific clinical question] (One to two sentences. Include laterality and precise location for musculoskeletal studies. If the indication is inadequate to answer the clinical question, explicitly state this.)

Comparison: [Most relevant prior study with date and modality / None available] (Never omit this line.)

Technique

[Number and type of views/projections; laterality for extremity exams; patient position/setting; any technical limitations and their impact on interpretation] (One brief sentence or semicolon-delimited clauses.)

Findings

[Image-based observations organized by anatomic region; laterality and specific locations; salient negatives addressing the indication; any limitations affecting diagnostic sensitivity if not stated in Technique] (Use short, precise sentences. Describe what is seen. Do not use subheadings. For normal studies, a brief statement confirming no significant abnormality is sufficient.)

Impression

1. [Diagnostic statement with laterality and location]
2. [Additional diagnostic statement or pertinent negative] (Include 1-5 items total, ordered by clinical urgency and relevance to the indication. Include follow-up recommendations as a numbered item when needed to clarify indeterminate findings or address potentially serious diagnoses.)

Communication

[Finding communicated; recipient name and role; method; date/time; acknowledgment status] (Include only when non-routine communication occurred for critical or unexpected findings. Omit this entire section for routine studies.)

Electronic Signature: [Radiologist name, credentials, and signature timestamp]