# 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.