Ultrasound breast report template
A structured ultrasound breast report template used for ultrasound breast. It covers 5 sections and 31 fields.
Demonstration content. Review and approve this template with your clinical lead before clinical use. Reference values shown in SonoTez are notes only and are never applied automatically.
Technique
High-frequency linear transducer ultrasound of the breast(s) and axilla.
What to include: sections and measurements
Right breast
- Background echotexture: homogeneous - fat · homogeneous - fibroglandular · heterogeneous
- Lesion: none seen · present
- Axilla: no abnormal-appearing nodes · abnormal-appearing nodes · not assessed
- Axillary description
Right breast lesions repeatable
- Clock-face position: 1 o'clock · 2 o'clock · 3 o'clock · 4 o'clock · 5 o'clock · 6 o'clock …
- Distance from nipple (cm)
- Size 1 (mm)
- Size 2 (mm)
- Size 3 (AP) (mm)
- Shape: oval · round · irregular
- Orientation: parallel · not parallel
- Margin: circumscribed · indistinct · angular · microlobulated · spiculated
- Echo pattern: anechoic · hyperechoic · complex cystic and solid · hypoechoic · isoechoic · heterogeneous
- Posterior features: none · enhancement · shadowing · combined
- Vascularity: absent · internal · rim
Left breast
- Background echotexture: homogeneous - fat · homogeneous - fibroglandular · heterogeneous
- Lesion: none seen · present
- Axilla: no abnormal-appearing nodes · abnormal-appearing nodes · not assessed
- Axillary description
Left breast lesions repeatable
- Clock-face position: 1 o'clock · 2 o'clock · 3 o'clock · 4 o'clock · 5 o'clock · 6 o'clock …
- Distance from nipple (cm)
- Size 1 (mm)
- Size 2 (mm)
- Size 3 (AP) (mm)
- Shape: oval · round · irregular
- Orientation: parallel · not parallel
- Margin: circumscribed · indistinct · angular · microlobulated · spiculated
- Echo pattern: anechoic · hyperechoic · complex cystic and solid · hypoechoic · isoechoic · heterogeneous
- Posterior features: none · enhancement · shadowing · combined
- Vascularity: absent · internal · rim
Other findings
- Other findings
Writing the impression
Answer the clinical question first, list the remaining findings in order of importance, and keep anything new out of the impression. If a structure was not fully seen, say so and give the reason. See how to write an ultrasound report for wording and certainty terms.