Radiology report templates by modality: X-ray, ultrasound, CT and MRI

What makes a good radiology report template?

A good radiology report template provides a clear, consistent set of headings and a sensible order for describing the study, while leaving plenty of room for free text. It should guide the report without dictating its content.

The best templates are short. Each prompt should earn its place by reminding the radiologist of something that is easy to forget or by making the report easier to read. Long lists of prompts that are usually answered "normal" tend to produce cluttered reports.

Templates should also be easy to change. Clinical questions vary, and the radiologist should be able to remove irrelevant prompts and add detail where it matters.

• Consistent headings in a predictable order.
• Few, purposeful prompts.
• Free text under every heading.
• Easy to adapt to the clinical question.

What sections should every template share?

Every template, whatever the modality, should share the same core sections: indication, technique, comparison, findings and conclusion. Keeping these common to all studies makes reports from different modalities feel familiar to the reader.

Modality-specific detail then sits mainly within the technique and findings sections. For example, an MRI template will list sequences under technique, while an X-ray template will list views. The conclusion section stays the same in every template: a short answer to the clinical question.

Medicate organises dictation into Indication, Findings and Conclusion. If you include technique and comparison details in your dictation, they are kept in your own words within those sections for you to review.

• Indication: the clinical question.
• Technique: views, sequences, phases or probe settings.
• Comparison: earlier studies reviewed, with dates.
• Findings: described in a consistent order.
• Conclusion: a direct answer to the question.

What does a plain X-ray report template look like?

A plain X-ray report template usually starts with the views obtained, then works through the relevant structures in a fixed order, and ends with a brief conclusion. Because X-ray reports are often short, the template should stay lean.

For a chest X-ray, a common order is lines and tubes if present, then the lungs and pleura, the heart and mediastinum, the bones and the soft tissues. For a limb X-ray, the order might be alignment, bones, joints and soft tissues. Image quality or positioning limitations are noted where relevant.

Many plain film reports can be completed in a few lines. The template is there to keep the order consistent, not to make the report longer.

• Technique: projections and any limitations.
• Comparison: earlier films, if available.
• Findings: a fixed anatomical order for the region.
• Conclusion: one or two lines answering the question.

What does an ultrasound report template look like?

An ultrasound report template typically records the type of examination and any technical limitations, then describes each organ or structure examined in turn, often with measurements, and closes with a conclusion. Because ultrasound is operator dependent, noting limitations is particularly useful.

For an abdominal ultrasound, the findings might be organised by organ: liver, gallbladder and bile ducts, pancreas, spleen, kidneys and any free fluid. For a targeted study, such as a soft tissue lump, the findings focus on the area of concern and its relationship to nearby structures.

Measurements should be recorded exactly as taken, with units. When dictating, say the numbers and units clearly and check them carefully at review, since numbers are easily misheard.

• Technique: examination type, approach and limitations.
• Findings: each organ or structure examined in turn.
• Measurements: stated clearly with units.
• Conclusion: summary focused on the clinical question.

What does a CT report template look like?

A CT report template usually records the region scanned, the phases acquired and whether contrast was given, then describes findings by body system or region, and ends with a prioritised conclusion. CT studies cover a lot of anatomy, so a consistent order is especially valuable.

For a CT of the chest, abdomen and pelvis, the findings might move from the chest through the abdominal organs, bowel, lymph nodes, vessels and bones. Many radiologists describe the area relevant to the clinical question first, then review the remainder of the study under a separate heading.

The conclusion should list the key findings in order of importance. Incidental findings that matter can be included, clearly separated from the answer to the main question.

• Technique: region, phases and contrast.
• Comparison: earlier cross-sectional imaging.
• Findings: area of clinical concern first, then the rest by system.
• Conclusion: key findings in order of importance.

What does an MRI report template look like?

An MRI report template records the sequences performed and any contrast given, then describes findings in a set anatomical order for the body part, and finishes with a concise conclusion. MRI reports can be detailed, so clear subheadings within the findings section help readers.

For an MRI of the knee, findings might be grouped under menisci, ligaments, cartilage, bone, extensor mechanism and soft tissues. For an MRI of the lumbar spine, they might cover alignment, vertebral bodies, each disc level in turn and the conus. Brain MRI templates often follow parenchyma, ventricles, extra-axial spaces and vessels.

Because MRI findings are often described level by level or structure by structure, dictating with the subheading spoken aloud keeps the draft easy to review.

• Technique: sequences, planes and contrast.
• Findings: grouped by structure or level with subheadings.
• Clear statements for each structure reviewed.
• Conclusion: concise and focused on the question.

How do you adapt templates without creating boilerplate?

Adapt templates by removing prompts that do not apply to the clinical question and by writing specific sentences rather than pasting default normal text. Boilerplate builds up when templates are filled in automatically and never edited.

Review your templates regularly with colleagues and referrers. Ask which parts they read and which they skip. A template that grows a new prompt every year without anything being removed will eventually become hard to use.

Finally, remember that a template is a starting point. The radiologist decides what each report needs to say, and the report should always read as a considered answer to a specific question.

• Delete prompts that are irrelevant to the request.
• Write specific sentences instead of default normal text.
• Review templates with colleagues and referrers.
• Remove old prompts when adding new ones.

Medicate does not impose a template. You dictate in your usual order, and it organises your words into Indication, Findings and Conclusion for you to review, correct and sign. It is designed never to add findings, measurements or laterality you did not dictate.

Frequently asked questions