Ultrasound report template
Breast Ultrasound report template
Copy a breast ultrasound report format into your reporting system. Record the area examined, replace the prompts with your findings, then complete the assessment and management plan. A normal example is shown below.
Technique: Breast ultrasound.
Typical indications: Palpable lump, focal pain, or targeted assessment after mammography.
Scope: For diagnostic breast ultrasound. Specify targeted or survey imaging, the side and the regions examined. Limit normal statements to that scope. Complete the assessment and management using the clinical and other imaging findings.
Report sections
The Ultrasound Breast report structure, section by section.
- Examination scope and site of concern
- Focal masses with morphology and orientation
- Cysts and ductal changes
- Skin and subcutaneous tissues
- Axilla for lymph nodes
- Overall ultrasound BI-RADS assessment
Normal breast ultrasound example
Synthetic targeted left breast examination with no sonographic abnormality. Adapt the final assessment and management to the complete clinical and imaging context.
- No focal sonographic abnormality at the specified site of concern in the left breast.
- BI-RADS 1 — Negative.
Plain-text scaffold
Copyable breast ultrasound report format
Copy this scaffold into your reporting system. Replace each bracketed prompt and remove any line you did not assess.
Independent blank scaffold, not a society-issued template. For reporting guidance, see the ACR breast ultrasound reporting guidance.
EXAM: [RIGHT / LEFT / BILATERAL] BREAST ULTRASOUND
CLINICAL DETAILS: [Indication, site of concern and relevant history]
COMPARISON: [Prior imaging and date, or no comparison available]
SCOPE AND TECHNIQUE: [Targeted or survey; side, regions examined and limitations]
FINDINGS:
Site of concern: [Sonographic findings at the specified clinical or imaging location]
Focal lesions: [Side, clock-face location, distance from nipple, size and morphology]
Other examined breast tissues: [Relevant findings within the scan scope]
Axilla, if examined: [Side and nodal findings]
Correlation: [Relationship to clinical, mammographic or MRI findings]
IMPRESSION:
[Concise summary answering the clinical question]
ASSESSMENT: [BI-RADS category and wording after complete review]
MANAGEMENT: [Recommendation based on the final assessment and clinical context]From dictation to finished report
Dictate your findings naturally. RadSpeed maps them onto the Ultrasound Breast structure above, keeps your reporting style, numbers the impression and returns clean text to your existing workflow. You do not fill in a form — you speak, and the structure is applied for you.
- Dictate the findings in any order.
- RadSpeed structures them into the sections above and drafts the impression.
- Review and sign off — the final wording stays yours.
This template is a reference scaffold with synthetic sample text. It is not clinical guidance, and the sample impression is illustrative only. RadSpeed is assistive software, not a diagnostic device. Never enter patient-identifiable information into public tools.