Mammography Report (Screening, BI-RADS)

Patient: [name and MRN or DOB]

Exam Date: [date]

Facility: [facility name/location]

Ordering Provider: [referring clinician]

Interpreting Radiologist: [name]

Exam Type: Screening Mammography

Indication

[Screening indication and relevant clinical history] (If no specific history is provided, use: "Screening mammography." Include prior breast cancer, biopsy, high-risk factors, or implants only if explicitly stated. Do not infer unverified risk factors.)

Technique and Comparison

[Modality, views obtained, and any significant limitations] (State digital mammography, tomosynthesis/DBT, or both. Note implant-displaced views if applicable. Document limitations only if present.)

Comparison: [prior mammogram dates, or "No prior mammograms available for comparison"]

Findings

Breast Density: [Category A: The breasts are almost entirely fatty / Category B: There are scattered areas of fibroglandular density / Category C: The breasts are heterogeneously dense, which may obscure small masses / Category D: The breasts are extremely dense, which lowers the sensitivity of mammography]

Right Breast: [findings or "No suspicious mass, calcifications, or architectural distortion"] (For recalled findings, specify type, location by quadrant or clock-face and depth, and size if measurable.)

Left Breast: [findings or "No suspicious mass, calcifications, or architectural distortion"] (For recalled findings, specify type, location by quadrant or clock-face and depth, and size if measurable.)

Impression

Assessment: [BI-RADS 1 – Negative / BI-RADS 2 – Benign / BI-RADS 0 – Incomplete: Need additional imaging evaluation / BI-RADS 0 – Incomplete: Need prior mammograms for comparison]

Recommendation: [Recommend routine screening mammography in 1 year. / Recommend diagnostic mammography and/or ultrasound for further evaluation of [finding, laterality, location].] (Ensure recommendation matches the assessment category. Do not recommend routine screening for BI-RADS 0.)