> ## Documentation Index
> Fetch the complete documentation index at: https://docs.bizaxl.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Diagnostic Reports
> How to create, compile, and share Diagnostic Reports at the Diagnostic and Scan Centre - the formal document that delivers scan and test findings to patients and referring doctors.
A Diagnostic Report is the end product of the investigation process. It is the formal document that compiles findings from one or more scans or blood tests and presents them in a clear, structured way. This is what the referring doctor receives and what the patient takes home.
**Who does this:** Healthcare Practitioner (Radiologist or Senior Physician)
**Requires:** At least one completed Clinical Procedure (scan) or an approved Lab Test.
***
## What a Diagnostic Report Contains
A Diagnostic Report is not just a summary - it is a clinical document that:
* Identifies the patient and the clinical question being answered
* Lists which investigations were performed and when
* Records structured findings from each investigation (via Observations)
* States the radiologist's or physician's interpretation and conclusion
* Includes any recommendations (further investigation, clinical referral)
***
## Creating a Diagnostic Report
Go to **Orders** in the workspace and click **Diagnostic Report**, then click **New**.
### Key Fields
| Field | What to Enter |
| ----------------------- | ---------------------------------------------------------------------------------------- |
| Patient | The patient this report is for |
| Document Type | The type of investigation (e.g., Clinical Procedure for scans, Lab Test for blood tests) |
| Document Name | The specific scan or test record being reported on |
| Healthcare Practitioner | The radiologist or physician authoring the report |
| Date | Date of the report |
***
## Adding Observations
Observations are the structured data entries inside the report. Each observation represents one specific finding or data point from the investigation.
In the **Test Items** or **Observations** table, click **Add Row** for each finding:
| Field | What to Enter |
| -------------------- | ---------------------------------------------------------------------------------------- |
| Observation Template | Select from the configured templates (e.g., "Lab Test" for image-based findings) |
| Result | The value, description, or conclusion for this observation |
| Attach Image | If using the "Lab Test" observation template, attach the scan image or report image here |
For a scan report, typical observations might include:
* "Impression: No acute intracranial abnormality detected" (for a brain CT)
* "Liver: Normal size and echogenicity" (for an abdominal USG)
* "Right knee: Medial meniscal tear noted in posterior horn" (for a knee MRI)
For a lab test report:
* Observation of the result image showing the haemoglobin value
***
## Adding the Conclusion
In the **Notes** or **Conclusion** field, write the overall clinical impression and any recommendation. This is the section that the referring doctor reads first. Be specific and actionable:
"CT brain (plain): No evidence of intracranial bleed or space-occupying lesion. Mild periventricular white matter changes, likely age-related. Clinical correlation recommended. No acute radiological emergency."
***
## Submitting the Report
Click **Submit** when the report is complete. A submitted Diagnostic Report:
* Is locked and cannot be edited
* Appears in the patient's Patient History timeline
* Becomes available to the patient on the patient portal
* Can be printed and handed to the patient or sent to the referring doctor
***
## Printing and Sharing the Report
From the submitted Diagnostic Report:
* Click **Print** to generate the printed report on the centre's letterhead. This is the copy handed to the patient and sent to the referring doctor.
* The patient can view the report on the patient portal after it is submitted.
* For email delivery, use the **Send Email** action from the report record.
***
## Linking Multiple Investigations to One Report
If a patient had both a scan and a blood test on the same visit and the doctor wants to compile both findings into one report, create one Diagnostic Report and add multiple rows in the Observations table - one set for the scan findings and one set for the lab findings.
***
## Diagnostic Report Field Reference
| Field | Purpose |
| ------------------------- | ----------------------------------------------------------- |
| Patient | The person the report is about |
| Document Type | Whether this is based on a Clinical Procedure or Lab Test |
| Document Name | The specific investigation record being reported on |
| Healthcare Practitioner | The radiologist or physician authoring the report |
| Date | Report date |
| Observations / Test Items | Structured findings, each linked to an Observation Template |
| Conclusion / Notes | Overall clinical impression and recommendations |
| Status | Draft / Submitted |
***
## Best Practices
* Always submit the Diagnostic Report on the same day the scan images are reviewed. Delays in report submission delay the patient's treatment decisions.
* Address the report to the referring doctor by name if the patient came on a referral. The printed report should be sent to the referring doctor, not just given to the patient.
* For normal or negative findings, state the normal findings explicitly (e.g., "No intracranial mass lesion identified") rather than simply writing "Normal." Explicit negative statements are more reassuring to the referring doctor.
* For findings that require urgent action, contact the referring doctor by phone immediately after submitting the report. Do not rely solely on the patient carrying the report to the doctor.
* Keep the conclusion brief and clear. The referring doctor reads hundreds of reports; a one or two sentence conclusion that answers their clinical question directly is more useful than a lengthy narrative.