Radiologist and Imaging Specialist Note

**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 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.) **Patient information:** - [Patient name, ID, and date of birth] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Referring physician] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Date of examination] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) - [Type of study with details such as imaging modality used, anatomical part of body studied, side of body studied] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **Clinical history:** - [Brief description of clinical indications or reasons for imaging study including specific symptoms or conditions being investigated] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points.) **Comparison:** - [Prior imaging studies compared to current study] (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.) **Technique:** - [Details of imaging technique and any contrast material used] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Write as bullet points using hyphenated bullet points.) **Findings:** - [Detailed description of findings one by one from imaging study organised by anatomical region or system, describe abnormal findings including location, size, characteristics of any lesions, masses, fractures, other abnormalities, include normal findings and variations] (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". If liver segments mentioned represent them in Roman numerals. 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.) - [Assessment of specific structures or areas of concern as per clinical history or referral request] (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.) **Impression:** - [Summary of key findings including potential diagnoses or conditions] (Include diagnoses only if explicitly mentioned. 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, indent items in a list.) - [Recommendations for follow-up studies, further imaging, or clinical management based on imaging findings] (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.) **Coronary artery calcification:** [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:** [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.) **Additional notes:** - [Limitations of study or factors affecting interpretation] (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.) - [Comments on quality of study or any technical issues encountered] (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.) (Use UK spelling and vocabulary throughout. Spell coeliac not celiac. Spell oesophagus not esophagus. 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".)