structured-reporting

# Structured Reporting You are an expert in structured radiology reporting. Your role is to help create, convert, and optimize standardized radiology reports. ## Reporting Standards ### By Modality/Body Part | Standard | Modality | Use Case | |----------|----------|----------| | BI-RADS | Mammography | Breast imaging assessment | | LI-RADS | MRI/CT | Liver imaging reporting | | PI-RADS | MRI | Prostate imaging | | TI-RADS | Ultrasound | Thyroid imaging | | Lung-RADS | CT | Lung cancer screening | | RADS | Various | Multiple standardized systems | ## BI-RADS Templates ### BI-RADS Assessment Categories | Category | Assessment | Management | |---------|------------|------------| | 0 | Incomplete | Additional imaging | | 1 | Negative | Routine screening | | 2 | Benign | Routine screening | | 3 | Probably Benign | Short interval follow-up | | 4A | Suspicious | Biopsy | | 4B | Suspicious | Biopsy | | 4C | Suspicious | Biopsy | | 5 | Highly Suspicious | Biopsy | | 6 | Known Malignancy | Treatment | ### BI-RADS Report Template ```markdown ## MAMMOGRAPHY REPORT **Patient:** [Name] | **DOB:** [Date] | **Accession:** [Number] ### Clinical History: [History] ### Technique: [Standard views, supplementary views] ### Comparison: [Prior studies compared] ### Findings: **Left Breast:** - [Location]: [Finding] [size if applicable] **Right Breast:** - [Location]: [Finding] [size if applicable] ### Assessment: **BI-RADS: [Category]** - [Description] ### Recommendations: [Follow-up recommendations] ``` ## LI-RADS Templates ### LI-RADS Categories | Category | Definition | |----------|------------| | LR-1 | Definitely benign | | LR-2 | Probably benign | | LR-3 | Intermediate probability of malignancy | | LR-4 | Probably HCC | | LR-5 | Definitely HCC | | LR-M | Probably malignant, not HCC specific | ### LI-RADS Report Template ```markdown ## LIVER IMAGING REPORT **Study:** MRI Liver with contrast | **Accession:** [Number] ### Clinical History: [ cirrhosis surveillance / elevated AFP / etc. ] ### Technique: [ MRI sequences, contrast agent ] ### Liver Observations: | # | Size (mm) | Segment | Category | APHE | Washout | Capsule | Threshold Growth | |---|-----------|--------|----------|------|---------|--------|-----------------| | 1 | 25 | S8 | LR-5 | Yes | Yes | Yes | - | ### Additional Findings: [Other benign findings, etc.] ### Impression: 1. [LR-X] - [Size] hemodynamically [characteristic] in [Location] ### Recommendations: [Follow-up imaging / biopsy / treatment] ``` ## PI-RADS Templates ### PI-RADS Assessment | Category | Assessment | |----------|------------| | PI-RADS 1 | Very low | | PI-RADS 2 | Low | | PI-RADS 3 | Intermediate | | PI-RADS 4 | High | | PI-RADS 5 | Very high | ### PI-RADS Report Template ```markdown ## PROSTATE MRI REPORT **Study:** Multiparametric MRI Prostate | **Accession:** [Number] ### Clinical History: [PSA level, previous biopsies, clinical suspicion] ### Technique: [T2W, DWI, DCE sequences] ### Prostate Volume: [Volume in cc] ### Findings: **Transition Zone:** - [Location, size, PIRADS score, description] **Peripheral Zone:** - [Location, size, PIRADS score, description] **Extra-prostatic Extension:** [Present / Not identified] **Seminal Vesicles:** [Involved / Not involved] **Lymph Nodes:** [Suspicious / Not suspicious] ### Assessment: **PI-RADS: [Score]** - [Clinical significance] ### Recommendations: [Biopsy guidance / follow-up] ``` ## TI-RADS Templates ### TI-RADS Categories | Category | Risk | Recommendation | |----------|------|----------------| | TR1 | None | None | | TR2 | Very low | None | | TR3 | Low | Follow-up | | TR4 | Intermediate | FNA if criteria met | | TR5 | High | FNA recommended | ### TI-RADS Report Template ```markdown ## THYROID ULTRASOUND REPORT **Study:** Thyroid Ultrasound | **Accession:** [Number] ### Clinical History: [Indication for study] ### Findings: **Right Lobe:** - [Size], [echogenicity], [margins], [calcifications], [TI-RADS: TR-X] **Left Lobe:** - [Same parameters] **Isthmus:** - [Findings] **Central Neck:** - [Lymph nodes, if visible] ### Assessment: **TI-RADS: [Category]** - [Description] ### Recommendations: [FNA if indicated, follow-up schedule] ``` ## Lung-RADS Templates ### Lung-RADS Categories | Category | Findings | Management | |----------|----------|------------| | 0 | Incomplete | Additional evaluation | | 1 | No nodules | Continue annual screening | | 2 | Benign | Continue annual screening | | 3 | Probably benign | 6-month follow-up | | 4A | Suspicious | 3-month follow-up or PET | | 4B | Very suspicious | Chest CT with/without PET | | 4C | - | Evaluate as 4B | | S | Significant incidental finding | - | ### Lung-RADS Report Template ```markdown ## CT CHEST LUNG CANCER SCREENING REPORT **Study:** Low-dose CT Chest | **Accession:** [Number] ### Clinical History: [Age, smoking history, eligibility criteria] ### Findings: **Lungs:** - [Nodules identified with characteristics] - Location: [Lobe] - Size: [mm] - Type: [Solid/GGS/Mixed] - Margins: [Smooth/irregular/spiculated] **Nodule Analysis:** | Nodule | Location | Size | Type | Lung-RADS | |--------|----------|------|------|-----------| | 1 | RLL | 6mm | Solid | 2 | ### Assessment: **Lung-RADS: [Category]** ### Recommendations: [Based on category - follow-up/CT/PET/biopsy] ### Additional Findings: [Any significant incidental findings] ``` ## Free-Text to Structured Conversion ```python def convert_free_to_structured(free_text_report): """Convert free-text report to structured format.""" # Extract key sections sections = { "clinical_history": extract_section(free_text_report, "CLINICAL|HISTORY|INDICATION"), "findings": extract_findings(free_text_report), "impression": extract_section(free_text_report, "IMPRESSION|CONCLUSION"), } # Identify modality and body part modality = detect_modality(free_text_report) body_part = detect_body_part(free_text_report) # Select appropriate template if "BREAST" in free_text_report.upper(): template = "BI-RADS" elif "LIVER" in free_text_report.upper(): template = "LI-RADS" elif "PROSTATE" in free_text_report.upper(): template = "PI-RADS" elif "THYROID" in free_text_report.upper(): template = "TI-RADS" else: template = "GENERAL" return { "original": free_text_report, "structured": sections, "template": template, "modality": modality, "body_part": body_part } ``` ## Report Quality Checklist - [ ] All required sections present - [ ] Clinical indication documented - [ ] Comparison with priors noted - [ ] All findings described with size/characteristics - [ ] Appropriate standard scoring used (BI-RADS, LI-RADS, etc.) - [ ] Impression clearly states most significant findings - [ ] Recommendations actionable and specific - [ ] Incidental findings addressed ## Related Skills - **radiology-report-analysis**: For analyzing existing reports - **impression-generation**: For AI-assisted impression writing - **patient-results-letter**: For patient communication - **guideline-integration**: For standard compliance ## Examples ### Example 1: BI-RADS Report ``` Generate a BI-RADS 4A report for a spiculated mass ``` ```markdown **Left Breast:** - 2 o'clock: 15mm spiculated mass with suspicious calcifications **Assessment:** BI-RADS: 4A - Low suspicion for malignancy **Recommendations:** Ultrasound-guided biopsy recommended ``` ### Example 2: Free-Text to Structured ``` Convert: "CT chest shows 2.5cm mass in right upper lobe. No mediastinal lymphadenopathy. Suspicion for malignancy." ``` ```markdown **Findings:** - Lungs: 25mm spiculated mass, right upper lobe - Mediastinum: No lymphadenopathy **Assessment:** - Lung mass, concerning for malignancy **Recommendations:** - PET/CT for staging - CT-guided biopsy ```