PATIENT NAME MRN # DATE OF SERVICE READING PHYSCIAN MODALITY REQUESTED BY CONFIDENCE IN QUALITY OF REPORT 1-4 scale definitions: Indicating agreement. Agreement in principle but would have worded differently. Miss by radiologist, however would not have resulted in a different treatment or outcome. Miss by radiologist which results in a different outcome or treatment. REQUEST OVERVIEW OF RADIOLOGY REPORT Y N REASON FOR REQUEST REQUEST ADDENDUM TO REPORT Y N QA RADIOLOGIST FINDINGS
PATIENT NAME MRN # DATE OF SERVICE READING PHYSCIAN MODALITY REQUESTED BY CONFIDENCE IN QUALITY OF REPORT 1-4 scale definitions: Indicating agreement. Agreement in principle but would have worded differently. Miss by radiologist, however would not have resulted in a different treatment or outcome. Miss by radiologist which results in a different outcome or treatment. Y N REQUEST OVERVIEW OF RADIOLOGY REPORT REASON FOR REQUEST Y N REQUEST ADDENDUM TO REPORT QA RADIOLOGIST FINDINGS
Quality-Assurance-confidence-form1.docx