Diagnostic-Report Scaffolds

These assets are structured field maps for authorized clinical services. They do not interpret data or produce a report suitable for patient care.

Radiology

The ACR Practice Parameter for Communication of Diagnostic Imaging Findings, revised 2025 (Resolution 9), addresses diagnostic imaging reports, final-report principles, preliminary reports, nonroutine communication, informal communication, and organizational communication policies.

Use assets/radiology_report_template.json only to map verified facts such as:

• examination identity and status;
• clinical indication as supplied;
• technique and documented limitations;
• comparison-source references;
• findings and impression authored by the qualified interpreting professional;
• nonroutine-communication record references;
• amendments/corrections and report version.

Do not:

• inspect or interpret images;
• generate normal findings, pertinent negatives, differential diagnoses, urgency, follow-up, or management recommendations;
• select BI-RADS, LI-RADS, Lung-RADS, PI-RADS, or another category;
• infer that a preliminary report is final;
• initiate, simulate, or document a communication that did not occur.

The responsible radiologist and organization control report content, communication, correction, and signature.

Pathology

CAP publishes and updates organ- and specimen-specific Cancer Protocols. The CAP template page showed protocol updates on 17 June 2026 and a Breast DCIS correction on 24 June 2026 when checked. Protocol versions and required/core or conditional elements can change.

Use assets/pathology_report_template.json only after a qualified pathologist selects:

• exact organ/site and specimen/procedure;
• current CAP protocol title and version, if applicable;
• applicable biomarker protocol and staging edition;
• local laboratory/reporting requirements.

For CAP synoptic reporting within its scope, core and conditionally required data elements are represented as data-element/response pairs; applicability depends on the exact current protocol.

Do not:

• generate a gross or microscopic observation;
• determine diagnosis, grade, stage, margin status, biomarker interpretation, or adequacy;
• apply a generic cancer checklist in place of the current exact protocol;
• convert cannot be determined or not applicable into a definitive value;
• create a signature or final diagnosis.

Laboratory

For applicable US nonwaived testing, 42 CFR 493.1291 addresses accurate and timely transmission, required report information, referral-laboratory handling, accessibility, and corrected reports. The exact regulation and laboratory policy control.

Use assets/lab_report_template.json only to map results already released by the performing laboratory or verified source system. Preserve:

• report status and version;
• performing laboratory/source-system reference;
• specimen and test identifiers held in the authorized system, not copied into examples;
• result, units, reference interval, flags, method, and comments exactly as released;
• correction link to both original and corrected reports;
• documented notification reference when one exists.

Do not:

• calculate, normalize, convert, interpret, flag, or suppress a patient result;
• supply a reference interval or “critical” threshold;
• infer specimen adequacy;
• recommend follow-up or treatment;
• alter a referral laboratory’s result or interpretation;
• release or sign a report.

Privacy and record integrity

Operational diagnostic reports often require identifiers for positive patient matching. This skill does not process those production records. It accepts only synthetic, de-identified, or aggregate manifests. Use institution-controlled systems for real clinical records and follow applicable access, retention, correction, audit, and disclosure procedures.

Every draft scaffold must remain DRAFT_NOT_FOR_CLINICAL_USE until the responsible licensed service reviews and completes it in its authorized system.