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Diagnostic Radiologist
20-25 minutes

Computed Tomography Scan Report

The s10.ai CT Scan Report template is expertly crafted for radiologists to meticulously document CT scan findings. Featuring sections for clinical information, scan technique, findings, impressions, and recommendations, this template empowers radiologists to deliver thorough reports across diverse anatomical regions, facilitating accurate diagnosis and effective treatment planning. Perfect for radiology departments, this template optimizes the reporting workflow, significantly improving communication with referring healthcare providers. Explore the s10.ai CT Scan Report template to enhance your radiological documentation and streamline clinical collaboration.

3,662 uses
4.7/5.0
G
Gareth Llewellyn
Template Structure

Organized sections for comprehensive clinical documentation

CT Imaging Report:
- Examined Area: [region of the body scanned] (only include if explicitly mentioned in the transcript)
Clinical Details:
- Reason: [reason for CT scan, clinical symptoms, or diagnosis] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Background: [relevant medical history, previous imaging studies, surgeries] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Procedure:
- [description of the CT scan technique, including type of scan, contrast use, and any special instructions] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Observations:
- [detailed description of the findings from the CT scan, including any abnormalities, measurements, relevant observations and comparisons with previous scans] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Conclusion:
- [summary of the key findings and clinical significance] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Suggestions:
- [suggested follow-up actions, additional tests, or referrals] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Radiologist:
- Name: [radiologist name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
- Date: [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 Scan Report:
- Body Parts: Abdomen and Pelvis
Clinical Information:
- Indication: Abdominal pain and suspected appendicitis
- History: Previous appendectomy, no prior imaging studies
Technique:
- A contrast-enhanced CT scan of the abdomen and pelvis was performed using a helical scanner. Oral and intravenous contrast were administered to enhance visualization.
Findings:
- The CT scan reveals a dilated appendix with surrounding fat stranding, consistent with appendicitis. No evidence of perforation or abscess formation. The liver, spleen, pancreas, and kidneys appear normal. No free air or fluid in the abdomen.
Impression:
- Findings are consistent with acute appendicitis. No complications observed.
Recommendations:
- Surgical consultation for appendectomy is recommended. No additional imaging is necessary at this time.
Radiologist:
- Name: Dr. Dafydd Ap Emyr
- Date: September 24, 2024
Clinical Benefits

Key advantages of using this template in clinical practice

  • The CT Scan Report template is an essential tool for healthcare professionals seeking to streamline the documentation of computed tomography findings. This comprehensive template is designed to enhance clinical accuracy and efficiency by providing structured sections for detailing the body region scanned, clinical indications, and relevant medical history. It includes a dedicated area for describing the CT scan technique, including the type of scan and any contrast use, ensuring precise documentation. Clinicians can meticulously record findings, noting any abnormalities or significant observations, and summarize key impressions for clinical significance. The template also facilitates clear communication of recommendations for follow-up actions or additional tests. By adopting this template, radiologists and clinicians can ensure thorough and consistent reporting, ultimately improving patient care and diagnostic outcomes.
Frequently Asked Questions

Common questions about this template and its usage

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Computed Tomography Scan Report