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The RSNA radiology reporting initiative is improving reporting practices by creating a library of clear and consistent report templates.

Supported in part by the National Institute of Biomedical Imaging and Bioengineering (NIBIB).

US Abdomen

 

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This page demonstrates the templates as a synoptic and hierarchical report, with the initial view showing only the template title and the major section headers of the report. By clicking on the section headers it is possible to drill into the content of the template.

Report
Procedure
[ ______ ]
Clinical information
Abdominal pain [ ______ ]
Elevated LFTs [ ______ ]
Fever [ ______ ]
Mass [ ______ ]
History of gallstones [ ______ ]
History of cholecystectomy [ ______ ]
[ ______ ]
Comparison
None [ ______ ]
[ ______ ]
Findings
Liver
Normal [ ______ ]
Size
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Normal [ ______ ]
Enlarged [ ______ ]
Small [ ______ ]
[ ______ ]
Echogenicity
Normal [ ______ ]
Hyperechoic
"Hyperechoic, consistent with hepatic steatosis"
Heterogeneous [ ______ ]
[ ______ ]
Contour
Smooth [ ______ ]
Nodular
"Nodular, consistent with cirrhosis"
[ ______ ]
Mass //Cystic or solid mass
None [ ______ ]
0+ Cyst
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Location
Lobe
Right lobe
Left lobe
Caudate lobe
Segment
Right anterior segment
Right posterior segment
Left lateral segment
Left medial segment
Couinaud segment
Segment 1
Segment 2
Segment 3
Segment 4A
Segment 4B
Segment 5
Segment 6
Segment 7
Segment 8
0+ Solid mass
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Location
Lobe
Right lobe
Left lobe
Caudate lobe
Segment
Right anterior segment
Right posterior segment
Left lateral segment
Left medial segment
Couinaud segment
Segment 1
Segment 2
Segment 3
Segment 4A
Segment 4B
Segment 5
Segment 6
Segment 7
Segment 8
[ ______ ]
Bile ducts
Common bile duct diameter
Not seen [ ______ ]
decimal
Normal [ ______ ]
Intrahepatic ducts dilated [ ______ ]
Extrahepatic duct dilated [ ______ ]
[ ______ ]
[ ______ ]
Gallbladder
Normal [ ______ ]
Not seen [ ______ ]
Cholecystectomy [ ______ ]
Gallstones
Present [ ______ ]
Absent [ ______ ]
[ ______ ]
Gallbladder sludge
Present [ ______ ]
Absent [ ______ ]
[ ______ ]
Gallbladder wall thickening
Present [ ______ ]
Absent [ ______ ]
[ ______ ]
Pericholecystic fluid
Present [ ______ ]
Absent [ ______ ]
[ ______ ]
Sonographic Murphy sign
Present [ ______ ]
Absent [ ______ ]
[ ______ ]
[ ______ ]
Pancreas
Normal [ ______ ]
Head
Not seen
"Obscured by bowel gas"
Normal [ ______ ]
Abnormal [ ______ ]
[ ______ ]
Uncinate process
Not seen
"Obscured by bowel gas"
Normal [ ______ ]
Abnormal [ ______ ]
[ ______ ]
Body
Not seen
"Obscured by bowel gas"
Normal [ ______ ]
Abnormal [ ______ ]
[ ______ ]
Tail
Not seen
"Obscured by bowel gas"
Normal [ ______ ]
Abnormal [ ______ ]
[ ______ ]
Spleen
Not seen [ ______ ]
Surgically absent [ ______ ]
Normal [ ______ ]
Size
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Splenomegaly
None [ ______ ]
Mild [ ______ ]
Moderate [ ______ ]
Severe [ ______ ]
Size
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
[ ______ ]
Right kidney
Not seen [ ______ ]
Normal [ ______ ]
Hydronephrosis
None [ ______ ]
Mild [ ______ ]
Moderate [ ______ ]
Severe [ ______ ]
[ ______ ]
Size
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Left kidney
Not seen [ ______ ]
Normal [ ______ ]
Hydronephrosis
None [ ______ ]
Mild [ ______ ]
Moderate [ ______ ]
Severe [ ______ ]
[ ______ ]
Size
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
Measurement [{decimal} mm | cm]
[ ______ ]
Abdominal aorta and IVC
Normal
"Visualized portions are normal"
[ ______ ]
Ascites
None [ ______ ]
Mild [ ______ ]
Moderate [ ______ ]
Severe [ ______ ]
[ ______ ]
Impression
[ ______ ]