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
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)
Comments/Notes: