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Diagnostic Radiologist
20-25 minutes

Imaging findings report

This radiology report template, tailored for radiologists, facilitates the documentation of imaging study findings, including X-rays, CT scans, and MRIs. It encompasses sections for patient demographics, examination specifics, imaging techniques, findings, impressions, and clinical recommendations. Radiologists can leverage this template to deliver a thorough summary of radiological findings and propose necessary follow-up actions. Optimized for integration with s10.ai, an AI-powered medical scribe, this template ensures precise and efficient documentation. It is perfect for radiologists aiming for a structured report format, thereby improving communication with referring healthcare providers.

3,395 uses
4.6/5.0
D
Dr. Sarah Thompson
Template Structure

Organized sections for comprehensive clinical documentation

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.)
• [Gender] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Referring Doctor:
• [Referring Physician Name] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
• [Referring Physician Contact Information] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Examination Information:
• [Type of Examination] (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 Indication] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Methodology:
• [Description of the technique used for the examination] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Observations:
• [Detailed description of the radiological findings] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Conclusion:
• [Summary of the radiological findings and clinical correlation] (only include if explicitly mentioned in the transcript, contextual notes or clinical note, otherwise leave blank.)
Suggestions:
• [Any follow-up recommendations or further imaging studies] (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 Contact Information] (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

Patient Information:
- John Doe
- Patient ID: 123456
- Date of Birth: 01/15/1980
- Gender: Male
Referring Physician:
- Dr. Emily Smith
- Contact Information: (555) 123-4567
Examination Details:
- Type of Examination: Chest X-ray
- Date of Examination: 10/10/2023
- Clinical Indication: Persistent cough and shortness of breath
Technique:
- Standard posteroanterior and lateral chest X-ray views were obtained.
Findings:
- The heart size is within normal limits. There is a mild increase in interstitial markings in the lower lung fields bilaterally, suggestive of early interstitial lung disease. No pleural effusion or pneumothorax is noted.
Impression:
- Findings are suggestive of early interstitial lung disease. Clinical correlation is recommended.
Recommendations:
- Recommend follow-up with a high-resolution CT scan of the chest for further evaluation.
Radiologist:
- Dr. Thomas Kelly
- Contact Information: (555) 987-6543
- Date of Report: 10/11/2023
Clinical Benefits

Key advantages of using this template in clinical practice

  • This comprehensive clinical template is designed to streamline the documentation process for healthcare professionals, ensuring accurate and efficient recording of patient information, examination details, and radiological findings. By incorporating high-search healthcare and clinical keywords, this template enhances searchability and accessibility, making it an invaluable tool for clinicians seeking to optimize their workflow. With sections dedicated to patient demographics, examination techniques, and detailed findings, this template facilitates thorough clinical assessments and supports informed decision-making. Clinicians are encouraged to adopt this template to improve documentation accuracy, enhance patient care, and ensure seamless communication within the healthcare team.
Frequently Asked Questions

Common questions about this template and its usage

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Imaging findings report