Discrepancy Report Form

Patient Name *

Medical Record Number *

Exam Type

Discrepancy Type *

Information Only: Additional findings for information only Minor Disagreement: Discordant findings that do not have a significant effect on patient management Major Disagreement: Significant discordant findings that may have untoward effect on patient outcome

Comments: Please describe the discrepancy *

Comments: Please describe any known follow up

Local Radiologist Name *

Please provide your email address if you would like a confirmation of receipt

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