EQUIP RADIOLOGIST IMAGE QUALITY FEEDBACK FORM
Reviewing Radiologist:_________________________
FACILITY:____________________________
Image Review Date:__________________________
Procedure:
This report is to be completed by an Interpreting Radiologist.
The radiologists should complete this form as needed for each case.
A system should be in place for analyzing feedback and taking measures for improvement as necessary.
Objective
To provide routine feedback on the quality of images performed by each active Radiology Technologist and images accepted for interpretation by each active Interpreting Physician.
Interpreting Physician (Original Reader) :_________________________ Patient Identifier:_______________________
Technologist's Name:_________________________ Date of Exam:_________________________
Overall Assessment
□Excellent □Good □Needs improvement, but do not repeat □Sub-Optimal, and should be repeated
Image Evaluation
Radiologist Image Quality Feedback Form : Sheet1
Additional Images Needed for Complete Breast Evaluation:
Requested views □RCC □LCC □RMLO □LMLO □Other View________________
Corrective Action Taken:
(If Applicable -- Circle One)
Addendum in MRS
Addendum in Fluency/PACS
Other (Provide Comments/Notes)_________________________________________________________________