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Sample  Reports

 

rScriptor Reports

High Quality Structured reporting

 

Below are several sample reports generated by rScriptor.  Additional sample reports can be found here.  In each example you will see what the radiologist dictated followed by the final report created by rScriptor.  Also demonstated are several different report formatting options.  rScriptor generates this final report and pastes it directly back into the dictation or word processing window allowing the radiologist to perform final edits before signing the report.

 

The radiologist has full control over the negative (normal) statements placed in the report.  These statements and the anatomy included in each report can be changed by the radiologist.  These changes are applied to all future reports.

 

Note the use of rScriptor keywords "Impression" and "Impression new" in the dictated text.  These keywords allow the radiologist to dictate the Findings and Impression sections simultaneously.  Keyword "Critical" moves the text to the top of the Impression section and (with certain options enabled) makes that line of text italicized or bold as demonstrated in Sample Report #2.  It can also be used to activate a critical reporting procedure if you have such a procedure in place.

 

Report Formatting Options

Customize your Reports

 

The following is a list of available report formatting options that can be applied to any report.  They can be customized to meet the needs of an individual hospital, referring practice or referring physician.  The radiologist does not need to change their dictation to change the format of their report.  The format can be applied automatically by rScriptor depending on the pre-defined formatting requirements set for that facility or referring physician.

 

  • double space findings
  • double space impression
  • bold headings (Exam, Findings, Impression, etc.)
  • bold findings items (Liver, Spleen, etc.)
  • capitalize all letters in the Findings section headings (LIVER, etc.)
  • italicize critical text in the impression
  • bold critical text in the impression
  • force advanced rScriptor use
  • highlight dictated text in the report
  • put impression first in report
  • put incidental statement in impression
  • italics positive findings
  • always use “long” version of report template when available
  • use “long” version of report template when report is a final report
  • provide minimal header information (for prelim reports only)
  • number impression
  • no blank lines in report
  • no blank lines in report except before FINDINGS: and IMPRESSION:
  • no normal findings displayed
  • no subheadings in findings section
  • keep text on same line as report heading
  • don't bullet impression, uses spaces
  • use exam title after Exam: in dictation rather than standard title
  • underline findings items (Liver, Spleen, etc.)
     

Sample Report #1

CT Abdomen and Pelvis

 

Dictated text:

3mm obstructing stone at the left UVJ with hydronephrosis left kidney.  Impression.

Calcified granulomata in the spleen.

Non-obstructing stones in each kidney the largest of which measures 5mm in the lower pole left kidney. Impression.

Normal appendix.  Negative.

Atalectasis in the lung bases.

Cholecystectomy.

 

 

Final report:

EXAM:

  CT Abdomen and Pelvis Without Intravenous Contrast.

 

CLINICAL HISTORY:

  28 year old female; Flank pain

 

TECHNIQUE:

  Axial computed tomography images of the abdomen and pelvis without intravenous contrast.

 

COMPARISON:

  No relevant prior studies available.

 

FINDINGS:

 

  LOWER THORAX:  Atalectasis in the lung bases.

 

 ABDOMEN:

 

  LIVER:  Unremarkable.

 

  GALLBLADDER AND BILE DUCTS:  Cholecystectomy.  No ductal dilation.

 

  PANCREAS:  Unremarkable.  No ductal dilation.

 

  SPLEEN:  Calcified granulomata in the spleen.  No splenomegaly.

 

  ADRENALS:  Unremarkable.  No mass.

 

  KIDNEYS AND URETERS:  3mm obstructing stone at the left UVJ with hydronephrosis left kidney.  Non-obstructing stones in each kidney the largest of which measures 5mm in the lower pole left kidney.

 

 PELVIS:

 

  BLADDER:  Unremarkable.  No stones.

 

  REPRODUCTIVE:  Unremarkable as visualized.

 

  APPENDIX:  Normal appendix.

 

 ABDOMEN & PELVIS:

 

  STOMACH AND BOWEL:  Unremarkable.  No obstruction.  No mucosal thickening.

 

  PERITONEUM:  Unremarkable.  No significant fluid collection.  No free air.

 

  LYMPH NODES:  Unremarkable.  No enlarged lymph nodes.

 

  VASCULATURE:  Unremarkable.  No aortic aneurysm.

 

  BONES:  No acute fracture.

 

IMPRESSION:    

 

1.    3mm obstructing stone at the left UVJ with hydronephrosis left kidney. 

 

2.    Non-obstructing stones in each kidney the largest of which measures 5mm in the lower pole left kidney. 

 

 

 

Final report (using the same dictation) with different formatting options applied

EXAM:  CT Abdomen and Pelvis Without Intravenous Contrast.

CLINICAL HISTORY:  28 year old female; Flank pain

TECHNIQUE:  Axial computed tomography images of the abdomen and pelvis without intravenous contrast.

COMPARISON:  No relevant prior studies available.

 

FINDINGS:

  Lower thorax:  Atalectasis in the lung bases.

  Liver:  Unremarkable.

  Gallbladder and bile ducts:  Cholecystectomy.  No ductal dilation.

  Pancreas:  Unremarkable.  No ductal dilation.

  Spleen:  Calcified granulomata in the spleen.  No splenomegaly.

  Adrenals:  Unremarkable.  No mass.

  Kidneys and ureters:  3mm obstructing stone at the left UVJ with hydronephrosis left kidney.  Non-obstructing stones in each kidney the largest of which measures 5mm in the lower pole left kidney.

  Bladder:  Unremarkable.  No stones.

  Reproductive:  Unremarkable as visualized.

  Appendix:  Normal appendix.

  Stomach and bowel:  Unremarkable.  No obstruction.  No mucosal thickening.

  Peritoneum:  Unremarkable.  No significant fluid collection.  No free air.

  Lymph nodes:  Unremarkable.  No enlarged lymph nodes.

  Vasculature:  Unremarkable.  No aortic aneurysm.

  Bones:  No acute fracture.

 

IMPRESSION:    

1.    3mm obstructing stone at the left UVJ with hydronephrosis left kidney. 

2.    Non-obstructing stones in each kidney the largest of which measures 5mm in the lower pole left kidney. 

 

 

 

 

Sample Report #2

CTA Chest, pulmonary embolism protocol

 

Dictated text:

Comparison: CT Chest dated 11/10/13.

1.1cm speculated nodule in the outer left breast.  Impression.  Recommend mammography evaluation.  Findings are worrisome for a breast cancer.

Small filling defect in a subsegmental pulmonary artery of the left lower lobe as seen on series 5, image 31.  Impression new.  Left lower lobe pulmonary embolism as described.  Low clot burden.

Old left-sided rib fractures.  No acute fracture.

Mild thoracic scoliosis.

No CT evidence of right heart strain.  Negative.

 

 

Final report:

EXAM:

  CT Angiography Chest With Intravenous Contrast.

 

CLINICAL HISTORY:

  28 year old female; Chest pain, SOB

 

TECHNIQUE:

  Axial computed tomographic angiography images of the chest with intravenous contrast using pulmonary embolism protocol.

  MIP reconstructed images were created and reviewed.

  Coronal and sagittal reformatted images were created and reviewed.

 

COMPARISON:

  CT Chest dated 11/10/13.

 

FINDINGS:

  PULMONARY ARTERIES:  Small filling defect in a subsegmental pulmonary artery of the left lower lobe as seen on series 5, image 31.

  AORTA:  No acute findings.  No thoracic aortic aneurysm.

  LUNGS:  Unremarkable.  No mass.  No consolidative infiltrate.

  PLEURAL SPACES:  Unremarkable.  No significant effusion.  No pneumothorax.

  HEART:  Unremarkable.  No cardiomegaly.  No significant pericardial effusion.  No CT evidence of right heart strain. 

  BONES, CHEST WALL:  1.1cm speculated nodule in the outer left breast.  Old left-sided rib fractures.  No acute fracture.  Mild thoracic scoliosis.

  LYMPH NODES:  Unremarkable.  No enlarged lymph nodes.

 

IMPRESSION:    

  Left lower lobe pulmonary embolism as described.  Low clot burden.

  1.1cm speculated nodule in the outer left breast.  Recommend mammography evaluation.  Findings are worrisome for a breast cancer.

 

 

 

 

Sample Report #3

MRI Lumbar Spine

 

Dictated text:

Comparison: XR Lumbar Spine dated 11/10/13.

Broad-based disc bulge with left paracentral disc protrusion at L5-S1 resulting in mild spinal canal stenosis and significant mass effect upon the traversing left-sided nerve roots.  Impression.

No neural foraminal stenosis at L5-S1.

Broad-based disc bulge at L4-L5 causing no spinal canal or neural foraminal stenosis.

Degenerative facet arthropathy lower lumbar spine.

 

 

Final report:

IMPRESSION:    

  Broad-based disc bulge with left paracentral disc protrusion at L5-S1 resulting in mild spinal canal stenosis and significant mass effect upon the traversing left-sided nerve roots. 

 

EXAM:

  MR Lumbar Spine Without Intravenous Contrast (72148).

 

CLINICAL HISTORY:

  28 year old female; Back pain

 

TECHNIQUE:

  Magnetic resonance images of the lumbar spine without intravenous contrast in multiple planes.

 

COMPARISON:

  XR Lumbar Spine dated 11/10/13.

 

FINDINGS:

  Vertebrae:  Degenerative facet arthropathy lower lumbar spine.  No acute fracture.  Normal alignment.

  Spinal cord:  Unremarkable.  Normal signal.

 

 DISCS/SPINAL CANAL/NEURAL FORAMINA:

  L1-L2:  Unremarkable.  No significant disc disease.  No stenosis.

  L2-L3:  Unremarkable.  No significant disc disease.  No stenosis.

  L3-L4:  Unremarkable.  No significant disc disease.  No stenosis.

  L4-L5:  Broad-based disc bulge at L4-L5 causing no spinal canal or neural foraminal stenosis.

  L5-S1:  Broad-based disc bulge with left paracentral disc protrusion at L5-S1 resulting in mild spinal canal stenosis and significant mass effect upon the traversing left-sided nerve roots.  No neural foraminal stenosis at L5-S1.