Diagnostic Imaging Peer Review Form
Please complete this form to provide a structured peer review of a diagnostic imaging study.
Imaging Study Type
*
Please Select
X-ray
CT
MRI
Ultrasound
Nuclear Medicine
Other
Date of Imaging Study
*
-
Month
-
Day
Year
Date
Image Quality Assessment
*
Poor
1
2
3
4
Excellent
5
1 is Poor, 5 is Excellent
Technical Adequacy
*
Adequate
Inadequate
Partially Adequate
Findings Agreement
*
Agree with findings
Minor discrepancies
Major discrepancies
Report Clarity
*
Unclear
1
2
3
4
Very Clear
5
1 is Unclear, 5 is Very Clear
Clinical Impact of Discrepancy
*
No impact
Minor impact
Major impact
Not applicable
Assessment Details
*
Rows
Strongly Disagree
Disagree
Neutral
Agree
Strongly Agree
Relevant clinical information provided
1
2
3
4
5
Appropriate imaging protocol used
6
7
8
9
10
Findings clearly described
11
12
13
14
15
Impression is appropriate
16
17
18
19
20
Recommendations or Suggestions
I confirm that this review was performed objectively and in accordance with institutional policies.
*
Yes, I confirm
No
Submit Review
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