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Radiology Specialist
30-45 minutes

Computed Tomography Report

The CT Report template from s10.ai is crafted specifically for diagnostic radiologists to effectively document CT scan findings. It features comprehensive sections for patient details, clinical history, CT techniques, detailed findings, impressions, and recommendations. By utilizing this template, radiologists can efficiently convey critical findings and clinical implications. Optimized for integration with s10.ai, an advanced AI medical scribe, this template ensures precise and thorough documentation. It is an excellent choice for radiologists aiming to enhance their reporting efficiency and elevate patient care through clear and concise communication.

4,966 uses
5/5.0
A
Aarav Patel
Template Structure

Organized sections for comprehensive clinical documentation

CT Examination Report:
Patient Details:
[Patient Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Patient ID] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Date of Birth] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Date of Examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Clinical Details:
[Indication for CT scan] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Relevant clinical history] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Procedure:
[Description of CT technique used, including contrast administration if applicable] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Observations:
[Detailed description of findings in each relevant anatomical area] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Conclusion:
[Summary of key findings and clinical implications] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Suggestions:
[Suggested follow-up or additional imaging if necessary] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Radiologist:
[Radiologist Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Radiologist Signature] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
[Date of Report] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Sample Clinical Note

Example of completed documentation using this template

CT Report:
Patient Information:
John Doe  
Patient ID: 123456  
Date of Birth: 01/01/1980  
Date of Examination: 10/15/2023  
Clinical Information:
Indication for CT scan: Assessment of ongoing headaches and dizziness.  
Relevant clinical history: History of migraines and recent head injury.  
Technique:
A non-contrast CT scan of the head was conducted using axial and coronal slices.  
Findings:
The CT scan shows no acute intracranial hemorrhage or mass effect. Mild sinusitis is observed in the maxillary sinuses. No signs of skull fracture.  
Impression:
The CT scan indicates no acute intracranial pathology. Mild sinusitis is present, which may be contributing to the patient's symptoms.  
Recommendations:
Consider consultation with an ENT specialist for sinusitis management. No further imaging is required at this time.  
Radiologist:
Dr. Thomas Kelly  
Radiologist Signature: T. Kelly  
Date of Report: 10/16/2023
Clinical Benefits

Key advantages of using this template in clinical practice

  • The CT Report template is an essential tool for healthcare professionals seeking to streamline and enhance their radiological documentation process. This comprehensive template is designed to capture critical patient information, clinical indications, and detailed findings, ensuring a thorough and accurate representation of the CT scan results. With sections dedicated to technique, findings, and impressions, clinicians can efficiently document and communicate key insights and clinical implications. The template also includes space for recommendations, facilitating informed decision-making and follow-up care. By adopting this template, radiologists and healthcare providers can improve the clarity and consistency of their reports, ultimately enhancing patient care and clinical outcomes. Explore the CT Report template today to optimize your radiological documentation workflow.
Frequently Asked Questions

Common questions about this template and its usage

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Computed Tomography Report