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).
数字化乳腺X线摄影（ACRIN 6652 /的DMIST）
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.
- 报告
- 图像演示和显示格式
-
GE - 软拷贝 -
Fischer - 软，硬拷贝
-
Lorad - CCD的硬拷贝
-
Lorad - 塞莱尼亚硬拷贝
-
富士 - 硬拷贝
-
- 以前的电影
-
有注释
-
没有注释
-
患者没有以前的胶片
-
- 发现
- 乳腺组织实质密度
-
-
几乎全部脂肪
-
分散的纤维腺密度
-
多相密集
-
非常密集
-
- 乳房X光摄影发现
-
-
否
-
是
-
- 肿块
-
否
-
是
-
多样化良性呈现肿块
-
临床相关肿块
- 临床相关的肿块数
- 总数
- nonNegativeInteger
- 右乳房
- nonNegativeInteger
- 左乳房
- nonNegativeInteger
- 1+ 肿块
- 临床相关的肿块数 [{positiveInteger} ]
-
右乳房
-
左乳房
-
- Ø-时钟位置
- //Check all that apply
-
1-2 -
2-3
-
3-4
-
4-5
-
5-6
-
6-7
-
7-8
-
8-9
-
9-10
-
10-11
-
11-12
-
12-1
-
腋尾 //Clock-face position and depth not required
-
乳晕下乳头 //Clock-face position and depth not required
-
仅在侧斜位见到 - 上级
-
仅在侧斜位见到 - 下级
-
仅在侧斜位见到 - 乳晕下
-
仅在CC见到 - 内侧
-
仅在CC见到 - 横向
-
仅在CC见到 - 乳晕下
- 深度
-
前部
-
中央
-
后部
-
前部和中央
-
中央和后部
-
前中央和后部
-
- 形状
-
圆形
-
椭圆形
-
分叶状
-
不规则状
-
- 边缘
- //Check all that apply
-
外切
-
微小叶
-
模糊
-
不清晰
-
针状
- 密度
-
高
-
相等
-
低
-
含脂肪
-
- 相关的功能
-
钙化
-
结构畸变
-
皮肤增厚
-
单独扩张导管
-
多重扩张管道
-
-
无
- 大小
- //largest dimension (mm)
- nonNegativeInteger
- "mm"
- 进一步诊断检查证明
-
没有证据 //There is NO evidence that the patient should be called back for
diagnostic work-up
-
有些证据 //There is SOME evidence that the patient should be called back
for diagnostic work-up
-
充分证据 //There is SUFFICIENT evidence that the patient should be called
back for diagnostic work-up
-
强有力的证据 //There is STRONG evidence that the patient should be called back
for diagnostic work-up
-
压倒性的证据 //There is OVERWHELMING evidence that the patient should be
called back for diagnostic work-up
-
- 恶性肿瘤级别
-
绝对不是恶性
-
几乎肯定不是恶性
-
也许不是恶性
-
可能是恶性
-
很可能是恶性
-
几乎肯定恶性
-
肯定恶性
-
- 恶性肿瘤的概率
- nonNegativeInteger
- maxInclusive (100)
- "%"
-
良性呈现和临床相关的肿块
- 临床相关的肿块数
- 总数
- nonNegativeInteger
- 右乳房
- nonNegativeInteger
- 左乳房
- nonNegativeInteger
- 1+ 肿块
- 临床相关的肿块数 [{positiveInteger} ]
-
右乳房
-
左乳房
-
- Ø-时钟位置
- //Check all that apply
-
1-2
-
2-3
-
3-4
-
4-5
-
5-6
-
6-7
-
7-8
-
8-9
-
9-10
-
10-11
-
11-12
-
12-1
-
腋尾 //Clock-face position and depth not required
-
乳晕下乳头 //Clock-face position and depth not required
-
仅在侧斜位见到 - 上级
-
仅在侧斜位见到 - 下级
-
仅在侧斜位见到 - 乳晕下
-
仅在CC见到 - 内侧
-
仅在CC见到 - 横向
-
仅在CC见到 - 乳晕下
- 深度
-
前部
-
中央
-
后部
-
前部和中央
-
中央和后部
-
前中央和后部
-
- 形状
-
圆形
-
椭圆形
-
分叶状
-
不规则状
-
- 边缘
- //Check all that apply
-
外切
-
微小叶
-
模糊
-
不清晰
-
针状
- 密度
-
高
-
相等
-
低
-
含脂肪
-
- 相关的功能
-
钙化
-
结构畸变
-
皮肤增厚
-
单独扩张导管
-
多重扩张管道
-
-
无
- 大小
- //largest dimension (mm)
- nonNegativeInteger
- "mm"
- 进一步诊断检查证明
-
没有证据 //There is NO evidence that the patient should be called back for
diagnostic work-up
-
有些证据 //There is SOME evidence that the patient should be called back
for diagnostic work-up
-
充分证据 //There is SUFFICIENT evidence that the patient should be called
back for diagnostic work-up
-
强有力的证据 //There is STRONG evidence that the patient should be called back
for diagnostic work-up
-
压倒性的证据 //There is OVERWHELMING evidence that the patient should be
called back for diagnostic work-up
-
- 恶性肿瘤级别
-
绝对不是恶性
-
几乎肯定不是恶性
-
也许不是恶性
-
可能是恶性
-
很可能是恶性
-
几乎肯定恶性
-
肯定恶性
-
- 恶性肿瘤的概率
- nonNegativeInteger
- maxInclusive (100)
- "%"
-
- 不对称密度
-
无
-
是
-
临床相关的不对称密度数
- 总数
- nonNegativeInteger
- 右乳房
- nonNegativeInteger
- 左乳房
- nonNegativeInteger
- 1+ 不对称密度
- 临床相关的不对称密度数字 [{positiveInteger} ]
-
右乳房
-
左乳房
-
- Ø-时钟位置
- //Check all that apply
-
1-2
-
2-3
-
3-4
-
4-5
-
5-6
-
6-7
-
7-8
-
8-9
-
9-10
-
10-11
-
11-12
-
12-1
-
腋尾 //Clock-face position and depth not required
-
乳晕下乳头 //Clock-face position and depth not required
-
仅在侧斜位见到 - 上级
-
仅在侧斜位见到 - 下级
-
仅在侧斜位见到 - 乳晕下
-
仅在CC见到 - 内侧
-
仅在CC见到 - 横向
-
仅在CC见到 - 乳晕下
- 深度
-
前部
-
中央
-
后部
-
前部和中央
-
中央和后部
-
前中央和后部
-
- 密度
-
高
-
相等
-
低
-
含脂肪
-
- 相关的功能
-
钙化
-
结构畸变
-
皮肤增厚
-
单独扩张导管
-
多重扩张管道
-
-
无
- 大小
- //largest dimension (mm)
- nonNegativeInteger
- "mm"
- 进一步诊断检查证明
-
没有证据 //There is NO evidence that the patient should be called back for
diagnostic work-up
-
有些证据 //There is SOME evidence that the patient should be called back
for diagnostic work-up
-
充分证据 //There is SUFFICIENT evidence that the patient should be called
back for diagnostic work-up
-
强有力的证据 //There is STRONG evidence that the patient should be called back
for diagnostic work-up
-
压倒性的证据 //There is OVERWHELMING evidence that the patient should be
called back for diagnostic work-up
-
- 恶性肿瘤级别
-
绝对不是恶性
-
几乎肯定不是恶性
-
也许不是恶性
-
可能是恶性
-
很可能是恶性
-
几乎肯定恶性
-
肯定恶性
-
- 恶性肿瘤的概率
- nonNegativeInteger
- maxInclusive (100)
- "%"
-
-
- 结构畸变
-
否
-
是 - 独立的肿块并不在别处报告这种形式
-
临床相关的结构畸变数
- 总数
- nonNegativeInteger
- 右乳房
- nonNegativeInteger
- 左乳房
- nonNegativeInteger
- 1+ 结构畸变
- 临床相关的结构畸变数 [{positiveInteger} ]
-
右乳房
-
左乳房
-
- Ø-时钟位置
- //Check all that apply
-
1-2
-
2-3
-
3-4
-
4-5
-
5-6
-
6-7
-
7-8
-
8-9
-
9-10
-
10-11
-
11-12
-
12-1
-
腋尾 //Clock-face position and depth not required
-
乳晕下乳头 //Clock-face position and depth not required
-
仅在侧斜位见到 - 上级
-
仅在侧斜位见到 - 下级
-
仅在侧斜位见到 - 乳晕下
-
仅在CC见到 - 内侧
-
仅在CC见到 - 横向
-
仅在CC见到 - 乳晕下
- 深度
-
前部
-
中央
-
后部
-
前部和中央
-
中央和后部
-
前中央和后部
-
- 大小
- //largest dimension (mm)
- nonNegativeInteger
- "mm"
- 进一步诊断检查证明
-
没有证据 //There is NO evidence that the patient should be called back for
diagnostic work-up
-
有些证据 //There is SOME evidence that the patient should be called back
for diagnostic work-up
-
充分证据 //There is SUFFICIENT evidence that the patient should be called
back for diagnostic work-up
-
强有力的证据 //There is STRONG evidence that the patient should be called back
for diagnostic work-up
-
压倒性的证据 //There is OVERWHELMING evidence that the patient should be
called back for diagnostic work-up
-
- 恶性肿瘤级别
-
绝对不是恶性
-
几乎肯定不是恶性
-
也许不是恶性
-
可能是恶性
-
很可能是恶性
-
几乎肯定恶性
-
肯定恶性
-
- 恶性肿瘤的概率
- nonNegativeInteger
- maxInclusive (100)
- "%"
-
-
与肿块相关并在别处报告这种形式
-
- 钙化簇
-
否
-
是 - 独立的肿块并不在别处报告这种形式
-
临床相关的钙化簇数
- 总数
- nonNegativeInteger
- 右乳房
- nonNegativeInteger
- 左乳房
- nonNegativeInteger
- 1+ 钙化簇
- 临床相关的钙化簇数 [{positiveInteger} ]
-
右乳房
-
左乳房
-
- Ø-时钟位置
- //Check all that apply
-
1-2
-
2-3
-
3-4
-
4-5
-
5-6
-
6-7
-
7-8
-
8-9
-
9-10
-
10-11
-
11-12
-
12-1
-
腋尾 //Clock-face position and depth not required
-
乳晕下乳头 //Clock-face position and depth not required
-
仅在侧斜位见到 - 上级
-
仅在侧斜位见到 - 下级
-
仅在侧斜位见到 - 乳晕下
-
仅在CC见到 - 内侧
-
仅在CC见到 - 横向
-
仅在CC见到 - 乳晕下
- 深度
-
前部
-
中央
-
后部
-
前部和中央
-
中央和后部
-
前中央和后部
-
- 钙化形态
-
良性呈现
-
-
皮肤钙化
-
血管钙化
-
粗 //Pop-corn Like
-
大杆似的
-
圆形
-
中心透明的
-
蛋壳或边缘
-
钙乳
-
缝合
-
营养不良型
-
点状
-
-
中级关注
-
无定形或模糊
-
-
恶性肿瘤的较高可能性
-
-
多形性或异质性 //Granular
-
精细线性或精细线性分支 //Casting
-
-
- 钙化簇数目
-
1-5
-
6-15
-
超过15
-
- 分配
-
分组和聚集
-
线性的
-
分段的
-
局部的
-
弥漫性或分散的
-
- 大小
- //largest dimension (mm)
- nonNegativeInteger
- "mm"
- //Evaluation of this cluster of calcifications
- 进一步诊断检查证明
-
没有证据 //There is NO evidence that the patient should be called back for
diagnostic work-up
-
有些证据 //There is SOME evidence that the patient should be called back
for diagnostic work-up
-
充分证据 //There is SUFFICIENT evidence that the patient should be called
back for diagnostic work-up
-
强有力的证据 //There is STRONG evidence that the patient should be called back
for diagnostic work-up
-
压倒性的证据 //There is OVERWHELMING evidence that the patient should be
called back for diagnostic work-up
-
- 恶性肿瘤级别
-
绝对不是恶性
-
几乎肯定不是恶性
-
也许不是恶性
-
可能是恶性
-
很可能是恶性
-
几乎肯定恶性
-
肯定恶性
-
- 恶性肿瘤的概率
- nonNegativeInteger
- maxInclusive (100)
- "%"
-
-
是 - 与肿块相关并在别处报告这种形式
-
-
右乳房
-
-
否
-
是
-
-
左乳房
-
-
否
-
是
-
-
-
- 印象
- //Overall Mammographic Impression
- 进一步诊断检查证明
-
没有证据 //There is NO evidence that the patient should be called back for
diagnostic work-up
-
有些证据 //There is SOME evidence that the patient should be called back
for diagnostic work-up
-
充分证据 //There is SUFFICIENT evidence that the patient should be called
back for diagnostic work-up
-
强有力的证据 //There is STRONG evidence that the patient should be called back
for diagnostic work-up
-
压倒性的证据 //There is OVERWHELMING evidence that the patient should be
called back for diagnostic work-up
-
- 恶性肿瘤级别
-
绝对不是恶性
-
几乎肯定不是恶性
-
也许不是恶性
-
可能是恶性
-
很可能是恶性
-
几乎肯定恶性
-
肯定恶性
-
- 恶性肿瘤的概率
- nonNegativeInteger
- maxInclusive (100)
- "%"
- 建议额外的诊断检查
-
无
-
超声波
-
短期间隔随访 //3-6 months
-
由转诊医生做的体检
-
外科会诊
-
Percutaneous biopsy with sonographic or stereotactic guidance
-
针，局部开放手术活检
-
附加乳房X光检查视图
-
乳腺磁共振成像
-
其他 [ ______ ]
-
-
- BIRADS分类
-
类别0 //Needs additional imaging
-
类别1 //Negative
-
类别2 //Benign Finding
-
类别3 //Probably Begign Finding - Short Interval Follow-up
Suggested
-
类别4 //Suspicious Abnormality - Biopsy should be
considered
-
类别5 //Highly Suggestive of Malignancy - Appropriate Action should
be Taken
-
- [ ______ ]