Quality Assurance Form

Hospital Name *

Patient Name

Patient Medical Record Number

Type of Study *

Date of Study *

Radiologist filling out form

IOC Reading Radiologist *

Email *

Phone # *

Fax #

Miss 0. Interpretation correct by syntax error in dictation.
Comments:

Miss 1. Incidental findings, not of clinical significance.
Comments:

Miss 2. Difficult case disagreement or missed diagnosis not ordinarily expected to be made.
Comments:

Miss 3a. Missed diagnosis, not related to ER presentation (No potential for adverse outcome if diagnosis made on final report).
Comments:

Miss 3b. Missed diagnosis, related to ER presentation (No potential for adverse outcome if diagnosis made on final report).
Comments:

Miss 4. Missed diagnosis. Potential for serious adverse outcome even if diagnosis made on final report.
Comments:

Please print a copy for your records prior to submitting the form. You will also receive a copy of your submission via email.