Mammography Report (Diagnostic, BI-RADS)

Patient Name: [patient name] (If unknown, enter "Not provided")

MRN/DOB: [second identifier - MRN or date of birth] (If unknown, enter "Not provided")

Exam Date: [date of examination] (If unknown, enter "Not provided")

Exam Type: Diagnostic Mammography [with Tomosynthesis / digital mammography only]

Facility: [facility name, city, state, ZIP, telephone number] (If unknown, enter "Not provided")

Interpreting Physician: [radiologist name and credentials] (If unknown, enter "Not provided")

Referring Clinician: [ordering provider name / Not provided]

Clinical Indication

[Indication category and details] (State reason for diagnostic mammography: symptom-directed, screening callback, or surveillance. Include laterality and location for symptoms or recalled findings. Add pertinent breast history only if it affects interpretation. If no indication provided, state: "Clinical history/indication not provided; interpretation limited to imaging findings.")

Comparison

[Prior studies with dates and facility if external / No prior studies available for comparison] (Include prior ultrasound or MRI only if reviewed and used to influence assessment.)

Technique

[Modality: digital mammography / digital mammography with tomosynthesis]. [Views obtained with laterality, including standard CC/MLO and any additional views such as spot compression, magnification, rolled views, or implant-displaced]. [Purpose of targeted views if applicable]. [Targeted breast ultrasound: side and indication, if performed as part of same diagnostic workup]

Findings

Breast Composition: [A: Almost entirely fatty / B: Scattered areas of fibroglandular density / C: Heterogeneously dense / D: Extremely dense]

Right Breast: [Findings description] (For each finding, include location with quadrant/clock position, finding type, and standardized BI-RADS descriptors. For masses: size, shape, margins, density. For calcifications: morphology, distribution, extent. Include targeted mammographic workup results and ultrasound correlation with concordance if applicable. If evaluating a symptom site with no mammographic correlate, state explicitly. If unremarkable, a brief negative statement is sufficient.)

Left Breast: [Findings description] (Same approach as right breast.)

Axillae: [Abnormal nodes if present] (Include only if abnormal nodes visible, axillary symptoms present, or nodal status relevant due to known malignancy. Omit if not applicable.)

Impression

1. [Key finding summary] (One sentence per actionable finding with laterality and location; do not restate full details.)
2. BI-RADS Final Assessment: [0: Incomplete - Need additional imaging / 1: Negative / 2: Benign / 3: Probably benign / 4A: Low suspicion / 4B: Moderate suspicion / 4C: High suspicion / 5: Highly suggestive of malignancy / 6: Known biopsy-proven malignancy] (Single overall category representing the most clinically significant finding.)
3. Management Recommendation: [Explicit, time-bound action] (Examples: return to routine screening; short-interval follow-up in 6 months; tissue diagnosis with recommended guidance method. If mammographic assessment is negative but symptom prompted imaging, address whether mammographic correlate exists and recommend next steps.)
4. Communication: [Who notified], [method], [date/time] (Include only when assessment is suspicious/highly suggestive or critical/time-sensitive.)