CT Report (Diagnostic)

Exam: [Standardized exam name including anatomic coverage and contrast status]

Date: [Acquisition date]

Facility: [Facility name] (Only include if multi-site practice)

Interpreter: [Attending radiologist name and credentials]

Status: [Preliminary / Final]

Indication

[Primary clinical question and relevant context in 1–3 sentences] (Include the symptom, suspected diagnosis, or specific question being asked; add pertinent history such as known malignancy, recent surgery, or trauma mechanism. Include relevant labs only if they affect interpretation. If clinical history was not provided, state: "No clinical history provided.")

Technique

[Acquisition details including anatomic coverage and reconstruction types as relevant]

IV contrast: [None / Agent, volume, and phase(s) acquired]

Enteric contrast: [None / Oral and/or rectal contrast type and volume] (Omit line if not applicable to exam type)

Radiation dose: [CTDIvol and DLP] (Or state: "Dose indices available in the dose report.")

Limitations: [Technical limitations and impact on diagnostic confidence] (Omit if none)

Comparison

[Prior studies reviewed with modality and date] (If none available, state: "No prior studies available for comparison." If priors exist but could not be accessed, state this explicitly.)

Findings

(Organize by organ system appropriate to the anatomy imaged. Lead with findings relevant to the clinical question. Provide location, size with measurements when clinically relevant, character, and complications. Include pertinent negatives addressing the indication. If a structure cannot be evaluated, state this explicitly. Include only the relevant regional section(s) below.)

Head/Brain

[Brain parenchyma, ventricles/extra-axial spaces, skull/skull base, sinuses/orbits findings] (Add vessels if angiographic study)

Neck

[Aerodigestive tract, salivary glands/thyroid, lymph nodes, bones/soft tissue findings] (Add vessels if angiographic study)

Chest

[Lungs/airways, pleura, mediastinum/hila, heart/pericardium, vessels, chest wall/bones findings]

Abdomen/Pelvis

[Liver/biliary, pancreas, spleen, adrenals, kidneys/ureters/bladder, GI tract, vasculature, lymph nodes, pelvic organs, peritoneum/mesentery, bones/soft tissues findings]

Spine

[Alignment, vertebrae, discs/facets/canal, paraspinal soft tissue findings]

Extremity

[Bones/joints, muscles/tendons/soft tissues findings] (Add vessels if relevant)

Impression

1. [Answer to the primary clinical question with diagnostic confidence and key limitations]
2. [Significant secondary finding with clinical implications]
3. [Actionable incidental finding with specific follow-up recommendation: study, timeframe, and rationale]

(Order by clinical urgency. Include only as many items as warranted. Avoid vague phrases without specific guidance.)