Radiology Report Template
Get a free Radiology Report Template for easy clinical documentation. Download the PDF and example here.
Fact Checked by Ericka Pingol.
What is a radiology test?
A radiology or medical imaging test is a diagnostic procedure to visualize the body's internal structures. This includes using X-rays, ultrasound, MRI, CT scans, and nuclear medicine, including bones, organs, and tissues.
Physicians commonly order radiology tests to help diagnose and monitor various medical conditions. These tests can help identify abnormalities, assess the extent of injuries or diseases, and guide treatment options. Some common types of radiology tests include:
- X-rays: Uses small amounts of radiation to produce images of bones, lungs, and other internal structures.
- Magnetic Resonance Imaging (MRI): Uses a strong magnetic field and radio waves to produce detailed images of organs and tissues.
- Computed Tomography (CT) scan: Uses X-rays and computer technology to produce cross-sectional body images.
- Nuclear medicine: Uses small amounts of radioactive material to diagnose and treat diseases.
Printable Radiology Report Template
Download this Radiology Report Template to convey the findings of a radiology test properly.
Why is a radiology report important?
A radiology report is a crucial document that conveys the findings of a radiology test to referring physicians. It represents the radiologist's expert interpretation of the imaging study, providing valuable information for diagnosis, treatment planning, and follow-up care.
The accuracy and clarity of these reports play a vital role in clinical decision-making, as they are integral to the continuum of patient care and improved patient outcomes. They offer a comprehensive review of the patient's condition and help assess the progression or resolution of a condition over time.
According to the Radiological Society of North America (n.d.), these structured reports serve as an "essential conduit for radiologists to convey their diagnostic input." Consistent, standardized reporting templates reduce confusion and enhance communication among healthcare professionals.
What is included in a radiology report?
A radiology report should include essential elements such as (American College of Radiology, n.d.):
- Radelement common data elements: The report should include specific patient data such as the location and description of the abnormality, any relevant history provided, and pertinent laboratory findings.
- Imaging technique section: A description of the imaging modality used. For example, CT scan, MRI, x-ray, etc.
- Description of imaging findings: This section provides a detailed analysis of what the radiologist has observed during the exam. It includes information about abnormalities or structures' size, shape, and appearance.
- Impression: This summary statement includes the radiologist's interpretation of the imaging findings and any further tests or treatment recommendations.
- Recommendation: This section outlines the radiologist's suggested next steps, such as follow-up imaging or consultations with other specialists.
How does our Radiology Report Template work?
Referring physicians, radiologists, and other healthcare professionals can utilize our free Radiology Report Template to create comprehensive and standardized reports for their patients quickly. Here's how to get started:
Step 1: Download the form
Get a copy of the structured report template using the link on this page. You may also get it from the Carepatron app or our resources library.
Step 2: Use the digital format or print a copy
You can use the digital version of our template, which can be filled out electronically. Alternatively, print a paper copy and fill it in by hand.
Step 3: Fill in the required information
To complete the report, enter all necessary patient data, including any relevant history and laboratory findings. Use the designated sections to describe imaging techniques and findings.
Step 4: Double-check and validate
Before submitting the report, review and verify all information for accuracy. Structured reporting drastically reduces the chances of mistakes, but it's always important to double-check.
Step 5: Submit the report
Once you have completed all sections and validated the information, submit the report to the appropriate parties involved in patient care. This may include referring physicians or other specialists needing to review the findings.
Radiology Report Template example
Our team has created a completed Radiology Report Template sample to give you an idea of how the form should look when filled out. Feel free to use this as a reference while completing your reports.
Download our free Radiology Report Template example here:
Why use Carepatron as your clinical documentation software?
Looking to streamline your clinical documentation process? Carepatron offers a comprehensive platform to streamline all your admin tasks. Some of our software features are:
- Easy patient access: Your patients can use our handy patient portal to access their medical records securely.
- Automated reminders: Our software includes automated appointment reminders for patients and task reminders for clinicians.
- Robust electronic health records (EHR): Automatically launch into your EHR system, eliminating the need for manual data entry and minimizing errors.
- Practical medical dictation system: Save time by dictating your reports directly into our platform and then having them transcribed automatically.
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References
American College of Radiology. (n.d.). PRACTICE PARAMETER Communication Diagnostic Findings / 1. Retrieved February 12, 2024, from https://www.acr.org/-/media/ACR/NOINDEX/Advocacy/Advocacy-News/Comm_Diag_Imaging.pdf?la=en
Radiological Society of North America. (n.d.). RadReport reporting templates. Www.rsna.org. https://www.rsna.org/practice-tools/data-tools-and-standards/radreport-reporting-templates
Commonly asked questions
A radiology report should be written after a diagnostic imaging procedure has been completed and a radiologist has reviewed the images.
You can modify this template to fit your practice's needs and preferences.
Radiologists, radiology technologists, and other healthcare providers use structured report templates to document their findings from diagnostic imaging procedures and communicate them with referring physicians.
