O RA TO RY , RA D IO L O G Y ,

LAB
A RD IO LO G Y R E P O R T IN G
AND C PRESENTED BY:
JAMAICA MAE F. SIBAYAN
JANILLA DAWN O. IFURUNG
LABORATORY REPORTING
According to the American Association for Clinical Chemistry, 2017 all
laboratory reports must possess common elements as required by institutional
and company policies.

For identification and filing purposes, some laboratory reports display elements
with administrative or clerical information such as the following:
• Px name and identification number or a unique identifier and identification no.
• Name and address of the laboratory location where the test was performed
• Date when report was printed
• Test report date
• Name of doctor or legally authorized person ordering the test(s)
 LABORATORY REPORTING CONT’D
Information about the specimen and the test itself, such as those included below,
are other elements that make a laboratory report more meaningful:
• Specimen source (if applicable) Interpretation of results
• Date and time of specimen collection Condition of specimen
• Laboratory accession number Deviations from test preparation
procedures
• Name of the test performed Medications, health supplements, etc.
• Test results taken by the patient.
• Abnormal test results
• Critical results
• Units of measurement (for quantitative results)
• Reference intervals (or reference ranges)
RADIOLOGY REPORTING
According to the University of Virginia (2013), a radiology report is an official
medical document that provides the details of the requested radiology
examination and the procedure conducted by the radiologist.
• A qualified physician authorized by the health care institution interprets the
report.
• The findings on the report should take into the account both positive and
negative findings.
• Important findings should be stated followed by incidental findings.
RADIOLOGY REPORTING CONT’D
Basic sections of a radiology report enumerated in the American College of
Radiology’s Practice guideline on communication must include the followings:

• Administrative identification
• Patient identification
• Clinical history
• Imaging technique
• Comparison
• Observations
• Summary or impression
• Signature of the radiologist
CARDIOLOGY REPORTING
Like other laboratory reports, contain medical information based on the test
results of the patient which are set against past medical records. Doctors are able
to write vascular reports much faster since access and retrieval on information are
made more convenient through computer systems.

• Using Cardiology information Systems (CIS), vascular reports are accurately

created with only few clicks, it includes ultrasonic ultrasound and diagrams.
• Nowadays, physician opt to provide automated reports through the use of
information systems.
• Medical staff can process lab reports for the approval of the physician. This
means that the results are generated more efficiently which translates to
improved patient experience.
KEY POINTS TO REMEMBER
• Laboratory, Radiology and Cardiology reporting allow information to be shared.
• The purpose of these reporting is to ORGANIZE, and COMMUNICATE to the patient
involved on the test requested.