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放射科质量管理(Radiology quality management)
Department of Radiology diagnostic report writing standard
A careful examination of the patients name, gender, age, date of inspection, inspection method and parts.
Two, the language concise and fluent, with appropriate words, accurate, clear and complete description.
Three, image description
1, the lesion: accurate positioning, in line with the human anatomy and imaging anatomy.
2 Description: change lesions, lesion density, shape, size, shape, edge, and adjacent organ structure and adjacent organ structure.
3, lesion size, lesion quantification: number degree.
4, and before and after treatment to compare the changes of reaction.
Four, conclusion (diagnosis or opinion)
1, writing format specification, order accuracy.
2, accurate diagnosis, no missing.
3, fill in the signature, the time of diagnosis.
Five, diagnostic opinion writing principles.
1, first, in normal lesions, the main disease, disease in earlier vice.
2, primary, secondary, first concurrent after illness earlier, chronic disease in the post.
3, need to be treated first, stable lesions in the posterior lesions.
4, organic lesions prior to functional changes in the post.
5, to answer clinical questions, also found in the first image.
6, sure, after diagnosis in earlier diagnosis of doubt.
7, infectious diseases, non communicable diseases in earlier.
CT inspection regulations
CT is a large, expensive equipment, strict management system.
1, keep indoor temperature (18-20C), humidity (40-60%), temperature, humidity and power supply does not meet the requirements, timely stop the report immediately.
2, keep indoor and machine clean, clean the ground bed. Usually nowindow, room, operating room to put debris. Reasonable placement room fire extinguisher.
3, skilled technicians scanner other ancillary equipment, in strict accordance with the rules of work, other personnel are not allowed to operate the machine, find and report the problems, and make a record.
4, in accordanc
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