Table 1 General information pertaining to the CMR report

Administrative

Site of service

Scanner

N/A

Site ID

Accreditation entity and status

Demographics

Unique patient ID

Patient date of birth (DOB) or age in years

Patient sex

Reasons for limited examinations

Summary of test findings

Physician signature and date (electronic signature and date must be clearly labeled)

Adequate description of test

Comparison with previous related studies

Patient Race/Ethnicity

Study referral data

Referring physician

N/A

Referring physician provider number

Referring physician specialty

Scheduling and performance of study

Date of procedure

Personnel involved in procedure

N/A

Time of procedure

Listing of sequences used

Black-blood

Late gadolinium enhancement (LGE)

Edema

Cine

Strain

Perfusion

Flow

Iron

MR angiography

N/A

N/A

History and risk factors

Height (in or cm)

Weight (lb or kg)

Body surface area (BSA)

Heart rate (beats per min)

Rhythm

Blood pressure brachial or femoral (specify which) arterial cuff systolic and diastolic blood pressure (mmHg)

For studies using contrast agents, value and date of the most recent serum creatinine and estimated glomerular filtration rate (eGFR)

N/A

Non-imaging findings associated with examinations

 Studies requiring 12-lead electrocardiogram

Interpretation

Rhythm

Ventricular rate

Presence of Q-waves

ST segment

T-wave abnormalities

N/A

N/A

 Tests incorporation stress testing

Heart rates and rhythm

Oxygen saturation

Maximum predicted heart rate response for age

Each should be recorded during following points in time and more frequently as clinically indicated: at pre-test baseline, at each level of stress, after recovery

N/A

Systolic and diastolic blood pressures

 Studies utilizing vasoactive or positive inotrope pharmacological cardioactive agents

Type of agent

Quantity of agent

Duration of agent

Route of administration

Associated medications and presence/absence of any side effects

N/A

N/A

 Studies utilizing contrast agents

Type and name of contrast agent

Volume of agent

Route of administration

Dosage of agent and presence/absence of any side effects

N/A

N/A

 Studies utilizing sedation

General anesthesia

Continuous display (hemodynamic or electric)

Recording of heart rate and rhythm and/or blood pressure

Type, volume, route of administration

Any side effects

Patient’s cardiovascular and pulmonary response

Reason for administration

N/A

N/A

Reporting criteria for CMR examinations

Standardized report format agreed upon in facility

Final report reviewed by interpreting member of medical staff

Final interpretations verified and signed by medical staff (manual or electronic) within 2 business days of study for routine studies, but reported on the same day for patients referred for major acute issues

Permanent record of interpretation

Defined mechanism whereby results which demonstrate urgent or life-threatening findings are communicated to appropriate healthcare professionals

If preliminary reports are issued, preliminary nature must be indicated

N/A