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Zhongwei Li
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skills/clinical-reports/assets/radiology_report_template.md
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skills/clinical-reports/assets/radiology_report_template.md
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# Radiology Report Template
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## Patient Information
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**Patient Name:** [Last, First]
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**Medical Record Number:** [MRN]
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**Date of Birth:** [MM/DD/YYYY]
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**Age:** [years]
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**Sex:** [M/F]
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**Exam Date:** [MM/DD/YYYY]
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**Exam Time:** [HH:MM]
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**Accession Number:** [Number]
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**Referring Physician:** [Name]
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**Ordering Service:** [Service/Department]
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---
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## Examination
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**Exam Type:** [CT/MRI/X-Ray/Ultrasound/PET/Nuclear Medicine scan]
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**Body Part:** [Anatomical region - e.g., Chest, Abdomen and Pelvis, Brain]
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**Contrast:** [Yes - IV/Oral/Both | No]
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**Laterality:** [Right/Left/Bilateral if applicable]
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---
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## Clinical Indication
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[Reason for examination, relevant clinical history, specific question to be answered]
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Example: "Rule out pulmonary embolism in patient with acute dyspnea and chest pain. History of recent surgery."
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---
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## Comparison
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**Prior Studies:**
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[Modality] of [body part] from [date]: [Available/Not available for comparison]
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Example: "CT chest without contrast from 6 months prior (01/15/2023) available for comparison"
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OR: "No prior imaging available for comparison"
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---
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## Technique
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[Detailed description of imaging parameters and protocol]
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**For CT:**
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```
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Multidetector CT of the [body region] was performed [without/with] intravenous
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contrast. [Volume] mL of [iodinated contrast agent name] was administered
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intravenously. Images were acquired in the [arterial/venous/delayed] phase(s).
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Multiplanar reconstructions were performed.
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Technical quality: [Adequate / Limited by motion artifact / Limited by patient body habitus]
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Radiation dose (DLP): [mGy-cm]
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```
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**For MRI:**
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```
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MRI of the [body region] was performed [without/with] intravenous contrast
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using the following sequences: [list sequences - T1, T2, FLAIR, DWI, etc.]
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[Volume] mL of [gadolinium-based contrast agent] was administered intravenously.
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Multiplanar imaging was obtained.
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Technical quality: [Adequate / Limited by motion artifact]
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```
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**For X-Ray:**
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```
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[Number] views of the [body part] were obtained: [AP/PA/Lateral/Oblique]
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Technical quality: [Adequate penetration and positioning / Limited by...]
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```
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**For Ultrasound:**
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```
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Real-time ultrasound examination of the [body part] was performed using
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[linear/curved] array transducer.
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Technical quality: [Adequate / Limited by bowel gas / Limited by body habitus]
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```
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---
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## Findings
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[Systematic, comprehensive description of findings organized by anatomical region or organ system]
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### [Region/Organ 1]
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[Detailed findings - size, density/intensity, enhancement pattern, abnormalities]
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**Normal statement:** "[Organ] is normal in size, contour, and [attenuation/signal intensity]. No focal lesions."
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**Abnormal statement:** "[Description of abnormality with measurements]"
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Example:
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```
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Lungs:
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- Bilateral ground-glass opacities are present, predominant in the lower lobes.
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- Right lower lobe consolidation measuring 4.5 x 3.2 cm with air bronchograms.
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- No pleural effusion or pneumothorax.
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- Airways are patent bilaterally.
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```
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### [Region/Organ 2]
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[Findings]
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### [Additional Regions as Applicable]
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**For Chest CT:**
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- Lungs
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- Airways
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- Pleura
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- Mediastinum and Hila
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- Heart and Great Vessels
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- Chest Wall
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- Upper Abdomen (if included)
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- Bones
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**For Abdomen/Pelvis CT:**
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- Liver
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- Gallbladder
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- Spleen
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- Pancreas
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- Kidneys and Adrenals
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- Gastrointestinal Tract
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- Peritoneum and Mesentery
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- Retroperitoneum
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- Bladder
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- Pelvic Organs
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- Vasculature
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- Lymph Nodes
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- Bones
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- Soft Tissues
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**For Brain MRI:**
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- Brain Parenchyma
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- Ventricles and Cisterns
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- Extra-axial Spaces
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- Vascular Structures
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- Orbits (if included)
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- Skull Base and Calvarium
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### Measurements (if applicable)
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| Structure | Measurement | Normal Range |
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|-----------|-------------|--------------|
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| [Lesion/mass] | [Size in cm, 3 dimensions] | - |
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| [Organ] | [Size] | [Normal size] |
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---
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## Impression
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[Concise summary of key findings with clinical interpretation]
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**Format as numbered list in order of clinical importance:**
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1. **[Most important finding]** - [Diagnosis or differential, clinical significance]
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- [Additional details, comparison to prior if applicable]
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- [Recommendation if any]
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2. **[Second finding]** - [Interpretation]
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3. **[Additional findings]**
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**Alternative format for normal study:**
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```
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No acute intrathoracic abnormality.
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Specifically, no evidence of pulmonary embolism.
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```
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**Recommendations (if applicable):**
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- [Further imaging, follow-up imaging interval, clinical correlation, biopsy, etc.]
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- [Timeframe for follow-up]
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Example:
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```
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Recommend follow-up CT in 3 months to assess for interval change.
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Clinical correlation with laboratory values recommended.
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Consider PET/CT for further characterization if clinically indicated.
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```
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---
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## Communication of Critical Results
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[If critical/urgent finding]
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**Critical finding:** [Description]
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**Communicated to:** [Name and role of person notified]
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**Date/Time:** [MM/DD/YYYY at HH:MM]
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**Method:** [Phone call / Page / In person]
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**Read back verified:** [Yes]
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---
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## Structured Reporting (if applicable)
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### For Lung Nodules (Lung-RADS):
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**Category:** [Lung-RADS 0/1/2/3/4A/4B/4X]
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**Recommendation:** [Per Lung-RADS guidelines]
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### For Breast Imaging (BI-RADS):
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**Category:** [BI-RADS 0/1/2/3/4/5/6]
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**Recommendation:** [Per BI-RADS guidelines]
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### For Liver Lesions (LI-RADS):
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**Category:** [LI-RADS 1/2/3/4/5/M/TIV]
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**Features:** [Arterial phase hyperenhancement, washout, capsule, size, growth]
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### For Prostate (PI-RADS):
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**Score:** [PI-RADS 1/2/3/4/5]
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**Location:** [Peripheral zone / Transition zone]
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---
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## Signature
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**Interpreted by:**
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[Radiologist name, MD]
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[Board certification]
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[NPI number if required]
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**Electronically signed:** [Date and time]
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**Dictated:** [Date and time]
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**Transcribed:** [Date and time]
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**Signed:** [Date and time]
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---
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## Template Notes
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### General Principles
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**Be systematic:**
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- Use consistent order (head to toe, outside to inside)
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- Don't skip regions even if normal
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- Include pertinent negatives
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**Be specific:**
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- Provide measurements (size in 3 dimensions for masses)
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- Describe location precisely
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- Use standardized terminology (RadLex)
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- Quantify when possible
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**Be clear:**
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- Avoid ambiguous language
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- Make impression stand-alone
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- Answer the clinical question directly
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- State what IS present, not just what isn't
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**Communication:**
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- Critical findings require immediate verbal notification
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- Document communication
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- Provide specific recommendations
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- Suggest next steps when appropriate
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### Measurement Guidelines
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**Lesions/Masses:**
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- Three dimensions: [length x width x height in cm]
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- Use consistent measurement method for follow-up
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**Lymph Nodes:**
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- Short axis diameter in cm
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- Note morphology (round vs. oval)
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**Organ Sizes:**
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- Use established normal ranges
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- Age and sex appropriate
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### Comparison Statements
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**Improved:**
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"Interval decrease in size of right upper lobe mass from 3.5 cm to 2.1 cm."
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**Stable:**
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"Unchanged 8 mm left lower lobe nodule, stable for 2 years."
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**Worsened:**
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"Interval increase in bilateral pleural effusions, now moderate on the right."
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**New finding:**
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"New 1.5 cm right adrenal nodule, not present on prior CT."
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### Differential Diagnosis Language
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**Definite:** "Consistent with..."
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**Probable:** "Most likely represents..." or "Favors..."
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**Possible:** "Suggestive of..." or "Differential diagnosis includes..."
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**Uncertain:** "Cannot exclude..." or "Consider..."
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### Recommendations
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**Follow-up imaging:**
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- Specify modality, timing, and what to assess
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- "Recommend CT chest in 6-12 months to assess stability"
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**Further characterization:**
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- "Consider MRI for further characterization"
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- "Ultrasound correlation recommended"
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**Clinical correlation:**
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- "Clinical correlation with tumor markers recommended"
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- "Correlate with patient symptoms and physical examination"
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**Biopsy/Intervention:**
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- "Consider biopsy for definitive diagnosis"
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- "Amenable to image-guided biopsy if clinically indicated"
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