The knowledge and skills that are required for radiological image interpretation are not well documented, even though medical imaging is gaining importance. This study aims to develop a comprehensive framework of knowledge and skills, required for two-dimensional and multiplanar image interpretation in radiology. A mixed-method study approach was applied. First, a literature search was performed to identify knowledge and skills that are important for image interpretation. Three databases, PubMed, PsycINFO and Embase, were searched for studies using synonyms of image interpretation skills or visual expertise combined with synonyms of radiology. Empirical or review studies concerning knowledge and skills for medical image interpretation were included and relevant knowledge and skill items were extracted. Second, a preliminary framework was built and discussed with nine selective experts in individual semi-structured interviews. The expert team consisted of four radiologists, one radiology resident, two education scientists, one cognitive psychologist and one neuropsychologist. The framework was optimised based on the experts comments. Finally, the framework was applied to empirical data, derived from verbal protocols of ten clerks interpreting two-dimensional and multiplanar radiological images. In consensus meetings adjustments were made to resolve discrepancies of the framework with the verbal protocol data. We designed a framework with three main components of image interpretation: perception, analysis and synthesis. The literature study provided four knowledge and twelve skill items. As a result of the expert interviews, one skill item was added and formulations of existing items were adjusted. The think-aloud experiment showed that all knowledge items and three of the skill items were applied within all three main components of the image interpretation process. The remaining framework items were apparent only within one of the main components. After combining two knowledge items, we finally identified three knowledge items and thirteen skills, essential for image interpretation by trainees. The framework can serve as a guideline for education and assessment of two- and three-dimensional image interpretation. Further validation of the framework in larger study groups with different levels of expertise is needed.