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Diagnostic Imaging Specialist
30-45 minutes

Chest CT Scan (Normal/Abnormal) Template

The CT Chest (Normal/Abnormal) template by s10.ai is meticulously crafted for radiologists to accurately document findings from high-resolution CT scans of the chest. This comprehensive template encompasses detailed sections for evaluating lung parenchyma, air-space opacities, interstitial lung disease, tracheal and bronchial findings, lymphadenopathy, cardiac size and morphology, pleural or pericardial effusion, mediastinal vessels, and the bony thoracic cage. Optimized for seamless integration with s10.ai, the AI medical scribe, this template enhances the efficiency and accuracy of clinical documentation. Radiologists seeking a structured and streamlined approach to reporting both normal and abnormal CT chest findings will find this template indispensable for improving workflow and diagnostic precision.

4,592 uses
4.9/5.0
A
Aarav Patel
Template Structure

Organized sections for comprehensive clinical documentation

CT Thorax (Plain) Report
Technique: Plain HRCT Scan of Thorax performed on Multidetector CT scanner. Images captured and assessed at suitable window settings.
Findings:
[Describe lung parenchyma findings in detail] (use "The visualised lung parenchyma shows normal attenuation and architectural pattern on both sides." if no lung parenchyma abnormalities are mentioned or if mentioned as normal)
[describe in detail any evidence of air-space opacities, collapse, consolidation, abscess, or pulmonary mass lesions] (use default sentence "No evidence of air-space opacities, collapse, consolidation, abscess or pulmonary mass lesion." if none of these abnormalities are specified)(if one or more of these abnormalities are mentioned, then do not include them in the above default sentence)
[describe in detail any signs of interstitial lung disease] (use "No signs of interstitial lung disease." if there is no mention of interstitial lung disease)
[describe trachea and bifurcation] (use "Trachea and bifurcation are normally seen." unless abnormalities are specified)
[describe bronchial findings] (use "No bronchial thickening or bronchiectasis is seen." unless abnormalities are specified)
[mention evidence of mediastinal or hilar lymphadenopathy] (use "No evidence of mediastinal or hilar lymphadenopathy." unless abnormalities are specified)
[describe heart size and shape] (use "Heart shows normal size and shape." unless abnormalities are specified)
[mention evidence of pleural or pericardial effusion] (use "No evidence of pleural or pericardial effusion." unless abnormalities are specified)
[describe mediastinal vessels] (use "The visualised mediastinal vessels show normal course and calibre." unless abnormalities are specified)
[describe bony thoracic cage] (use "Bony thoracic cage is normal. No lytic or sclerotic lesion in visualised bones." unless abnormalities are specified)
(Note any additional findings or observations specific to this case)
Impression
[list each impression or diagnosis with brief description](use "CT Thorax Plain study is within normal limits." if impression is normal)
(Never come up with your own patient details, findings, diagnosis, impression or plan - use only the transcript, contextual notes, or clinical note as a reference for the information to include in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state that the information has not been explicitly mentioned in your output, instead use the default normal sentence provided to you for that placeholder)
(Do not use bullet points. Only write in complete sentences. For each placeholder, use as many sentences as needed to capture all the relevant information from the transcript. Each placeholder should be on a new line.)
Sample Clinical Note

Example of completed documentation using this template

CT Chest (Plain) Report
Technique: A plain HRCT scan of the chest was performed using a multidetector CT scanner. Images were captured and assessed at suitable window settings.
Findings:
The observed lung parenchyma exhibits normal attenuation and structural pattern on both sides.
There is no indication of air-space opacities, collapse, consolidation, abscess, or pulmonary mass lesion.
No evidence of interstitial lung disease is present.
The trachea and bifurcation appear normal.
No bronchial thickening or bronchiectasis is observed.
There is no evidence of mediastinal or hilar lymphadenopathy.
The heart maintains a normal size and shape.
There is no indication of pleural or pericardial effusion.
The visualized mediastinal vessels have a normal course and caliber.
The bony thoracic cage is normal. No lytic or sclerotic lesions are seen in the visualized bones.
Impression
The CT Chest Plain study is within normal limits.
Clinical Benefits

Key advantages of using this template in clinical practice

  • The CT Chest (Plain) Report template is an essential tool for radiologists and clinicians seeking a comprehensive evaluation of the chest using a high-resolution CT scan. This template ensures a detailed assessment of the lung parenchyma, identifying any abnormalities such as air-space opacities, collapse, or pulmonary mass lesions. It also provides a thorough examination of interstitial lung disease signs, trachea and bifurcation, bronchial findings, and potential mediastinal or hilar lymphadenopathy. Additionally, the template evaluates the heart's size and shape, checks for pleural or pericardial effusion, and assesses the mediastinal vessels and bony thoracic cage. By adopting this template, healthcare professionals can ensure accurate and efficient documentation, facilitating better patient outcomes and streamlined clinical workflows. Explore this template to enhance your diagnostic capabilities and improve patient care.
Frequently Asked Questions

Common questions about this template and its usage

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