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