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Peer Review Form
Please fill out the form
1
Step 1
2
Step 2
3
Step 3
*
Reviewer:
*
First Name
*
Last Name
This field is required.Please enter value
This field is required.Please enter value
*
Performing Sonographer:
*
First Name
*
Last Name
This field is required.Please enter value
This field is required.Please enter value
*
Accession Number:
This field is required.Please enter value
The value allows only numbers
Invalid number!
The value must be greater than or equal to -21474836487
The value must be less than or equal to 2147483647
Mobile No:
This field is required.Please enter value
Invalid phone number.
The value must be less than or equal to 20
Indication:
This field is required.Please enter value
Exam:
Appendix
Pylorus
Baby Head
Spine
This field is required.Please enter value
Grayscale Images
Focus and Depth Optimized:
Always
Mostly
Sometimes
Rarely
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Gain and TGCs Optimized :
Always
Mostly
Sometimes
Rarely
This field is required.Please enter value
Annotations and Preset Optimized:
Always
Mostly
Sometimes
Rarely
This field is required.Please enter value
Appropriate clip taken:
Yes
No
This field is required.Please enter value
Appropriate Probes Used:
Yes
No
This field is required.Please enter value
Rate the overall quality of the study:
This field is required.Please enter value
Additional Comments:
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Measurements
Additional comments:
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Color Doppler
Is the color gain optimized:
Yes
No
This field is required.Please enter value
Is the color gain optimized:
Yes
No
This field is required.Please enter value
Additional Comments:
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Worksheet
Yes
No
N/A
Spelling Accurate
Additional Charges Noted
Appropriate patient comments added
Labs and procedure comments added
Pathology/Incidental findings noted
Results communicated when needed
Prior imaging comparisons
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Overall Worksheet Quality:
This field is required.Please enter value
Appropriate Protocol Followed:
Yes
No
This field is required.Please enter value
Additional Comments:
This field is required.Please enter value
Dictation
Radiologist:
This field is required.Please enter value
Does the dictation correlate with the worksheet:
Very well
Somewhat
Hardly
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Is the dictation accurate:
Yes
No
Accurate Spelling
Comprehendible
All-inclusive
Accurate
Additional Comments:
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