Radiology Assessment Report

---
name: radiology-assessment-report
description: |
  Assess patients referred for diagnostic imaging and referring clinicians and write a defensible findings report as a radiologist.
  TRIGGERS - Use when a radiologist needs a assessment & findings report for patients referred for diagnostic imaging and referring clinicians in a hospital imaging department.
category: Radiology
license: MIT
version: 1.0
---
# Assessment & Findings Report — Radiology

Assess patients referred for diagnostic imaging and referring clinicians and write a defensible findings report as a radiologist. The deliverable is a structured assessment report with findings, evidence and recommendations.
This skill is written for a radiologist working with patients referred for diagnostic imaging and referring clinicians in a hospital imaging department.

## When to use
- You are a radiologist preparing, delivering or reviewing this part of your work in a hospital imaging department.
- You need a defensible, repeatable approach that produces a structured assessment report with findings, evidence and recommendations.
- A colleague, auditor or client asks how this was done and what evidence supports it.

## Key Concepts
| Term | Meaning |
|------|---------|
| PACS | the system storing and displaying medical images |
| Contrast | a substance given to make structures visible on scans |
| Modality | a type of imaging, such as CT, MRI or ultrasound |

## Workflow
1. **Step 1** - Review the intake record and imaging reports so the assessment builds on verified information, not assumptions
2. **Step 2** - Carry out the assessment using CT scanners, following the recognised method for a hospital imaging department
3. **Step 3** - Compare findings against the benchmarks behind report turnaround time and note where evidence is strong, weak or missing
4. **Step 4** - Draft the report: findings first, then interpretation, then recommendations in priority order
5. **Step 5** - Check the draft for accuracy and for missed findings on imaging; have it reviewed where the profession's standards require a second sign-off

## Profession-Specific Components
| Component | Details for Radiology |
|-----------|-------------------------------|
| Core documentation | imaging reports; scan protocols; contrast consent forms; radiation dose records |
| Core tools & equipment | CT scanners; MRI scanners; ultrasound systems; PACS workstations |
| People involved | patients referred for diagnostic imaging and referring clinicians; the radiologist; colleagues and other services in a hospital imaging department |
| Primary record | imaging reports — keep it current, dated and attributable |

## Output Format
**Context:** [Situation in a hospital imaging department] | **Objective:** [What this must achieve] | **Audience:** [patients referred for diagnostic imaging and referring clinicians and other stakeholders]

The finished output is a structured assessment report with findings, evidence and recommendations, structured as:
1. Summary of position and evidence
2. Detail, following the workflow above
3. Decisions, actions, owners and dates
4. Review point and escalation route

### Action Plan
1. **Immediate:** Confirm scope, consent and the evidence available in imaging reports.
2. **Short-term:** Complete the workflow steps and record outcomes against report turnaround time.
3. **Medium-term:** Review results, close actions, and update local procedures in a hospital imaging department.

## Success Metrics
| Metric | Target | Method |
|--------|--------|--------|
| report turnaround time | Agree a local target and track the trend | Measured from imaging reports and reviewed on a set cycle |
| critical finding communication rate | Agree a local target and track the trend | Measured from imaging reports and reviewed on a set cycle |
| repeat scan rate | Agree a local target and track the trend | Measured from imaging reports and reviewed on a set cycle |
| dose audit compliance | Agree a local target and track the trend | Measured from imaging reports and reviewed on a set cycle |

## Guardrails & Quality Checks
- Never let this happen: missed findings on imaging.
- Never let this happen: radiation overexposure.
- Never let this happen: contrast reactions.
- Work only within the competence and authority of a radiologist; escalate or refer anything beyond it.
- Record facts and observations, not speculation, and keep records confidential to a hospital imaging department's rules.
- Verify names, dates, figures and measurements twice before anything is issued or signed off.
- Use only real, verified information from the case in hand — never invent results, credentials or evidence.

## Example (illustrative)
A radiologist in a hospital imaging department applies this workflow for patients referred for diagnostic imaging and referring clinicians: they open
imaging reports, work through the five steps using CT scanners, and close by recording
the outcome against report turnaround time and agreeing the next review date. (Illustrative example only —
replace with the real details of the case in hand.)