Radiologist Chest CT Scan Template

**Scan date:** [Date of scan] (If dates described in format MM YY then use numerical month and 4 digit year and do not add DD, do not use a day in the date. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Clinical information:** [Clinical information provided] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points. If no clinical information then do not add this section.) **Prior imaging:** [Prior imaging studies or note if none available for comparison] (Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". If series and image references given write them in context of dictation verbatim. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points.) **Chest and thorax:** [Thorax findings] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) **Abdomen and pelvis:** [Liver, spleen, pancreas, common bile duct and gallbladder findings] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. If liver segments mentioned represent them in Roman numerals. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Adrenal glands findings] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Kidneys findings including any cysts, masses, stones, or calculi] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Ureters and urinary bladder findings] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Colon, rectum, sigmoid, descending colon, transverse colon, ascending colon findings including pericolic fat stranding, lymph nodes, fluid or adenopathy] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Large bowel condition] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Terminal ileum, ileocaecal valve, and appendix findings] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Small bowel pathology presence or absence] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Stomach contents and any abnormalities] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Peritoneal, retroperitoneal or pelvic lymph nodes presence or absence] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Ascites presence or absence] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Uterus, adnexa or gynaecological structures findings] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) **Bones, joints and soft tissues:** [Malignant bony abnormalities or metastases] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Incidental findings such as degenerative disease] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) [Subcutaneous or other soft tissue abnormalities including breast pathology] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Avoid using "is seen" or "is present" when not specifically dictated. State whether descriptions conclude normal or not normal or abnormal. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Where multiple items described as normal then list them together rather than separately if possible. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points, indent items in a list.) **Conclusion:** [Referrer alert] (If phrase "insert referrer" or "referrer" is used then type "**ALERT: COPY REPORT TO REFERRING CLINICIAN". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Conclusion] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Substitute dictated word "query" with "?". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points.) "Please note that endoluminal upper and lower GI malignancy along with bladder malignancy cannot be excluded and direct visualisation should be considered in order to fully exclude malignancy from the imaged volume." [Summary of findings with recommendations for clinical correlation and any suggested follow-up] (Use present tense for description of current CT and relevant past tense for descriptions of prior scans or findings. Where staging or lymph node levels or any kind of grading with numbers is used use numerical values rather than written form. Use millimetres as mm, use centimetres as cm. If measurements described using word "by" then substitute with "x". Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points.) [Coronary artery calcification statement] (If coronary artery calcium or calcification mentioned do not add dictated or transcribed statement but instead add line space and then state "Incidental [mild or moderate or severe] coronary artery calcification demonstrated. If the patient has associated symptoms of angina, recommend management as per chest pain guidelines, including cardiology referral if appropriate. If the patient is asymptomatic, routine cardiology referral not required, GP and/or referring clinician to consider reviewing modifiable cardiovascular risk factors and managing as per guidelines for primary prevention." Use mild, moderate, or severe depending on what was mentioned. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) [Valve calcification statement] (If aortic or mitral valve calcification mentioned and severity mentioned do not add dictated or transcribed statement but instead add line space and then state "[Mild or moderate or severe] [mitral or aortic or mitral and aortic] valve calcification. This may indicate the presence of [mitral or aortic or mitral and aortic] valve stenosis. Consider echocardiography if clinically appropriate." Reference mitral, aortic, or mitral and aortic depending on what was mentioned and mild, moderate, or severe depending on what was mentioned. Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) (Use UK spelling and vocabulary throughout. Spell coeliac not celiac. Spell oesophagus not esophagus. Spell oesophageal not esophageal. If contradictions in information highlight in capitals. If errors between left and right highlight in capitals. If errors between superior and inferior findings highlight in capitals. If contradictions in positive and negative findings highlight in capitals. If contradictions in report highlight in capitals. If patient stated as female and prostate mentioned highlight "CHECK SEX OF PATIENT". If patient is male and gynaecological organs, uterus, ovaries mentioned highlight "CHECK SEX OF PATIENT".)