Free reference · for radiologists and residents

    Radiology report templates and examples

    Ten plain-text templates in the standard Exam / Indication / Technique / Comparison / Findings / Impression format: normal reports for the common CT, MRI, radiograph, ultrasound and mammography exams, plus two worked examples that show how a finding and its guideline-based recommendation are carried into the impression. Copy, paste into your dictation system, adapt to your department protocol.

    CT templateCT head without contrast — normal

    EXAM: CT HEAD WITHOUT CONTRAST

CLINICAL INDICATION: [Headache / trauma / altered mental status].

TECHNIQUE: Axial non-contrast CT images of the head were obtained with coronal and sagittal reformats. Dose-reduction techniques were used.

COMPARISON: None.

FINDINGS:
Brain: No acute intracranial hemorrhage, mass effect, or midline shift. No evidence of acute territorial infarct. Gray-white differentiation is preserved. Ventricles and sulci are normal in size and configuration for age. Basal cisterns are patent.
Extra-axial spaces: No extra-axial fluid collection.
Skull: No acute fracture.
Sinuses/mastoids: Paranasal sinuses and mastoid air cells are clear.
Orbits: Unremarkable on the included images.

IMPRESSION:
No acute intracranial abnormality.

    CT templateCT chest with contrast — normal

    EXAM: CT CHEST WITH IV CONTRAST

CLINICAL INDICATION: [Indication].

TECHNIQUE: Helical CT of the chest was performed after administration of [__] mL of intravenous contrast. Axial images with coronal and sagittal reformats. Dose-reduction techniques were used.

COMPARISON: [None / prior study date].

FINDINGS:
Lungs and airways: Lungs are clear. No pulmonary nodule, consolidation, or pleural effusion. Central airways are patent.
Mediastinum and hila: No mediastinal or hilar lymphadenopathy. Heart size is normal. No pericardial effusion. Thoracic aorta is normal in caliber. Pulmonary arteries are normal in caliber.
Chest wall and bones: No aggressive osseous lesion. No chest wall mass.
Upper abdomen: Visualized upper abdominal organs are unremarkable.

IMPRESSION:
No acute or significant abnormality in the chest.

    Worked exampleCT chest — incidental 6 mm nodule (worked example with Fleischner recommendation)

    EXAM: CT CHEST WITH IV CONTRAST

CLINICAL INDICATION: Chest pain.

TECHNIQUE: Helical CT of the chest after intravenous contrast. Axial images with coronal and sagittal reformats.

COMPARISON: None.

FINDINGS:
Lungs and airways: 6 mm solid noncalcified nodule in the right lower lobe (series 3, image 142). No additional nodules. No consolidation or pleural effusion. Central airways are patent.
Mediastinum and hila: No lymphadenopathy. Heart size normal. No pericardial effusion.
Chest wall and bones: Unremarkable.
Upper abdomen: Unremarkable.

IMPRESSION:
1. 6 mm solid noncalcified right lower lobe pulmonary nodule, indeterminate.
2. Per Fleischner Society 2017 guidelines for a single solid 6–8 mm nodule in a low-risk patient, follow-up CT chest at 6–12 months is recommended; if stable, consider CT at 18–24 months. If the patient is high risk, CT at 6–12 months then at 18–24 months.

(This is the recommendation step that gets lost in free dictation. GigHz Precision AI detects the nodule statement and places the applicable Fleischner guidance in the impression for the radiologist to confirm.)

    CT templateCT abdomen and pelvis with contrast — normal

    EXAM: CT ABDOMEN AND PELVIS WITH IV CONTRAST

CLINICAL INDICATION: [Abdominal pain].

TECHNIQUE: Helical CT of the abdomen and pelvis in the portal venous phase after administration of [__] mL of intravenous contrast. [Oral contrast was / was not administered.] Coronal and sagittal reformats. Dose-reduction techniques were used.

COMPARISON: [None].

FINDINGS:
Liver: Normal size and attenuation. No focal hepatic lesion.
Gallbladder and biliary tree: No gallstones or wall thickening. No biliary ductal dilatation.
Pancreas: Unremarkable. No pancreatic ductal dilatation.
Spleen: Normal size. No focal lesion.
Adrenal glands: Unremarkable bilaterally.
Kidneys and ureters: Symmetric enhancement. No hydronephrosis, renal calculus, or focal renal lesion.
Bladder: Unremarkable.
Reproductive organs: Unremarkable.
Gastrointestinal tract: No bowel obstruction, wall thickening, or inflammatory change. Appendix is normal.
Peritoneum and mesentery: No free fluid or free air. No lymphadenopathy.
Vasculature: Abdominal aorta is normal in caliber.
Bones and soft tissues: No acute or aggressive osseous lesion.

IMPRESSION:
No acute abnormality in the abdomen or pelvis.

    Radiography templateChest radiograph, two views — normal

    EXAM: CHEST RADIOGRAPH, PA AND LATERAL

CLINICAL INDICATION: [Cough / shortness of breath].

COMPARISON: [None].

FINDINGS:
Lungs are clear. No focal consolidation, pleural effusion, or pneumothorax. Heart size and mediastinal contours are within normal limits. Pulmonary vascularity is normal. Osseous structures are unremarkable.

IMPRESSION:
No acute cardiopulmonary abnormality.

    MRI templateMRI brain with and without contrast — normal

    EXAM: MRI BRAIN WITH AND WITHOUT IV CONTRAST

CLINICAL INDICATION: [Indication].

TECHNIQUE: Multiplanar, multisequence MRI of the brain was performed before and after administration of [__] mL of intravenous gadolinium-based contrast, including sagittal T1, axial T2, FLAIR, diffusion-weighted imaging with ADC map, susceptibility-weighted imaging, and post-contrast T1 sequences.

COMPARISON: [None].

FINDINGS:
No acute infarct on diffusion-weighted imaging. No intracranial hemorrhage, mass, or abnormal enhancement. Ventricles and sulci are normal in size and configuration. No midline shift. White matter signal is normal for age. Flow voids of the major intracranial arteries are preserved. Pituitary gland and sella are unremarkable. Visualized orbits, paranasal sinuses, and mastoid air cells are clear.

IMPRESSION:
Normal MRI of the brain. No abnormal enhancement.

    MRI templateMRI lumbar spine without contrast — normal

    EXAM: MRI LUMBAR SPINE WITHOUT CONTRAST

CLINICAL INDICATION: [Low back pain / radiculopathy].

TECHNIQUE: Sagittal T1, T2, and STIR sequences and axial T1 and T2 sequences through the lumbar spine.

COMPARISON: [None].

FINDINGS:
Alignment: Normal lumbar lordosis. No spondylolisthesis.
Vertebral bodies: Normal height and marrow signal. No fracture or focal marrow lesion.
Conus and cauda equina: Conus medullaris terminates at [L1]. Cauda equina nerve roots are unremarkable.
Discs and levels:
L1-L2 through L5-S1: No significant disc bulge, herniation, spinal canal stenosis, or neural foraminal narrowing. Facet joints are unremarkable.
Paraspinal soft tissues: Unremarkable.

IMPRESSION:
No significant degenerative disc disease, spinal canal stenosis, or neural foraminal narrowing in the lumbar spine.

    Worked exampleMRI liver — observation in cirrhosis (worked example with LI-RADS category)

    EXAM: MRI ABDOMEN WITH AND WITHOUT IV CONTRAST (LIVER PROTOCOL)

CLINICAL INDICATION: Cirrhosis; hepatocellular carcinoma surveillance.

TECHNIQUE: Multiphase MRI of the abdomen before and after intravenous extracellular gadolinium-based contrast, including arterial, portal venous, and delayed phases, with T2, diffusion-weighted, and in/opposed-phase sequences.

COMPARISON: Ultrasound [date].

FINDINGS:
Liver: Nodular contour consistent with cirrhosis. 2.3 cm observation in segment VIII (series 7, image 31) demonstrating nonrim arterial phase hyperenhancement, nonperipheral washout on the portal venous and delayed phases, and an enhancing capsule. No threshold growth can be assessed (no prior cross-sectional imaging). No additional observations. Main portal vein is patent.
Biliary tree, gallbladder, pancreas, spleen, adrenals, kidneys: Unremarkable. Splenomegaly measuring 14 cm.
Peritoneum: Trace perihepatic ascites.

IMPRESSION:
1. 2.3 cm segment VIII observation with arterial phase hyperenhancement, washout, and enhancing capsule: LI-RADS 5 (definitely hepatocellular carcinoma) by LI-RADS v2018 criteria (size 20 mm or greater with two or more major features).
2. Cirrhosis with splenomegaly and trace ascites.

(Precision AI recognizes the major-feature language during dictation and proposes the LI-RADS category with its criteria for the radiologist to confirm.)

    Ultrasound templateUltrasound abdomen, complete — normal

    EXAM: ULTRASOUND ABDOMEN, COMPLETE

CLINICAL INDICATION: [Abdominal pain / elevated liver enzymes].

COMPARISON: [None].

FINDINGS:
Liver: Normal size and echotexture. No focal hepatic lesion. Hepatopetal flow in the main portal vein.
Gallbladder: No gallstones, wall thickening, or pericholecystic fluid. Negative sonographic Murphy sign.
Biliary tree: Common bile duct measures [__] mm. No intrahepatic biliary ductal dilatation.
Pancreas: Visualized portions are unremarkable.
Spleen: Normal size, measuring [__] cm.
Kidneys: Right kidney [__] cm, left kidney [__] cm, with normal cortical echogenicity. No hydronephrosis or renal calculus.
Aorta and IVC: Normal caliber where visualized.
Other: No ascites.

IMPRESSION:
Normal complete abdominal ultrasound.

    Mammography templateScreening mammogram — normal (BI-RADS 1)

    EXAM: SCREENING DIGITAL MAMMOGRAM, BILATERAL [WITH TOMOSYNTHESIS]

CLINICAL INDICATION: Screening.

COMPARISON: [Prior mammograms dated __].

FINDINGS:
Breast composition: [Scattered areas of fibroglandular density (B)].
There is no suspicious mass, architectural distortion, or suspicious calcification in either breast. No significant change from prior examinations.

IMPRESSION:
Negative screening mammogram. No mammographic evidence of malignancy.

ASSESSMENT: BI-RADS Category 1 — Negative.

RECOMMENDATION: Routine annual screening mammography.

    The template is the easy part. The recommendation is what gets dropped.

    GigHz Precision AI is AI radiology reporting software that listens to natural dictation, structures it into this format, and surfaces the applicable Fleischner, Lung-RADS, LI-RADS, Bosniak or TI-RADS guidance in the impression for the radiologist to confirm. $99/month for attendings, $49 for residents, PowerScribe-compatible workflow.

    See GigHz Precision AI Precision AI vs PowerScribe →

    Questions

    What sections does a radiology report have?

    The standard format is: exam name, clinical indication, technique, comparison, findings organized by organ or region, and an impression that lists the significant findings and any follow-up recommendation. Screening mammography adds a BI-RADS assessment and recommendation.

    Why put the follow-up recommendation in the impression?

    Referring clinicians read the impression, often only the impression. Guideline-based management, for example Fleischner follow-up intervals for an incidental lung nodule or a LI-RADS category for a liver observation, belongs there so it is acted on. Omitting it is the most common documentation gap in free dictation.

    Can I paste these templates into PowerScribe or another dictation system?

    Yes. They are plain text in the common section order, with bracketed fields for the values you dictate. Adapt the organ list to your department protocol.

    Educational reference. Templates are generic and must be adapted to local protocols and the individual examination; guideline citations (Fleischner 2017, LI-RADS v2018, BI-RADS) are summarized, not reproduced. Written by Pouyan Golshani, MD, interventional radiologist.

    Written and reviewed by Pouyan Golshani, MD, Interventional Radiologist — Last updated June 12, 2026

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