Radiology Report

Radiology Report Components

Following are the key components to a radiology report:

• Facility where study was performed
• Patient identifying information (name + another identifier)
• Name of ordering physician
• Imaging modality (type of radiologic examination)
• Examination date
• Clinical indication
• Previous images used for comparison
• Procedures & materials (contrast media and/or radiopharmaceuticals, catheters, devices, etc. used)
• Findings
• Potential limitations (factors compromising radiologic examination)
• Impression (where diagnosis and/or differential diagnosis is included)

Radiology Report Mock Example

Saint Joseph’s Hospital

Name: Jane Doe
Hospital Number: 00001
Age: 68
Sex: Female
Race: White

Ordering Physician: Dr. Jane Smith

Exam Performed: US ABD LIMITED

LIMITED ABDOMINAL ULTRASOUND

Clinical Indication: Ascites.

Comparison: None.

Findings: A survey of the four quadrants of the abdomen was performed.

The patient was scanned in the supine position. There is a diffuse ascites within the right upper, right lower, and left lower quadrants. An “X” was placed on the skin within the right lower quadrant. The distance from the skin to the beginning of the fluid is 1.0 cm. The distance from the skin to the middle of the fluid is 3.9 cm.

Impression: Moderate diffuse ascites. Marking placed within the right lower quadrant.

Radiology
Date: 01/01/2018

Updated: June 8, 2018