DIAGNOSTIC REPORT FORM
Include the following items in a letter format:
Patient's Name and ID. Name of Referring Physician. Date of signature of Informed Consent.
Date of procedure and Institution performing the examinations.
Dear Dr (Name of Referring Physician):
The result of the (Procedure) performed on (Patient's Name ), is as follows:
Clinical History: Patient's age and gender, diagnosis or referral
information. Add any other relevant data.
Quality Control: Describe procedures in this regard (especially for Radiotracer
and Equipment).
Comments: Any event which might affect the diagnostic examination being
performed is listed here.
Description: Note in detail, abnormal features you see in the patient images in
particular those related to the diagnosis under study.
Interpretation and Conclusions:
1) Interpretation refers to physiologic and pathologic syndrome or abnormality.
2) Conclusions, refers to most likely aetiology. Suggested follow-up of patient.
Dr (Name of Reporting Physician). Name of Physician validating the report.
e-mail and Cel Phone.
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