Radiologist CT Thorax Abdomen Pelvis Report Template

[Type of scan in capitals] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely.) **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] (Only include if explicitly mentioned in transcript, contextual notes, or clinical note, else omit section entirely. Summarise the clinical information. Write as bullet points using hyphenated bullet points.) **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.) **Technique** [Description of technique 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** **Unenhanced findings** [Unenhanced 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. 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.) **Post-contrast findings** [Post-contrast 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. 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.) **General abdomen and pelvis findings** [General abdomen and pelvis 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. 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.) **Thorax/chest/other findings** [Thorax, chest, or other 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. 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.) **CONCLUSION** [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". 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. 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 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".)