Normal Diagnostic Breast Ultrasound Report Template (BI-RADS 1)
Normal targeted diagnostic breast ultrasound report template with clock-face location, BI-RADS category 1 assessment and mammographic correlation wording.
EXAMINATION: Targeted ultrasound of the [right/left] breast. CLINICAL HISTORY: [indication, e.g., palpable lump or mammographic finding at the [x] o'clock position]. COMPARISON: [date of prior mammogram/ultrasound, or None available]. TECHNIQUE: Real-time grayscale and color Doppler imaging of the [right/left] breast, targeted to the [x] o'clock position, [x] cm from the nipple, correlating with the [palpable/mammographic] area of concern. FINDINGS: At the site of clinical concern there is no solid or cystic mass, no architectural distortion and no abnormal shadowing. Normal fibroglandular tissue is present in the region scanned. Skin and subcutaneous tissues: Normal thickness. Axilla: No abnormal axillary lymph node in the imaged portion. IMPRESSION: 1. No sonographic abnormality at the site of clinical concern. BI-RADS Category 1 — Negative. RECOMMENDATION: [Continue routine screening mammography / clinical follow-up of the palpable finding as warranted].
Dictation notes
- Document the exact region scanned — clock position, distance from the nipple and transducer sweep — or a later cancer at that site becomes indefensible.
- A negative ultrasound does not dismiss a suspicious palpable finding; the recommendation should return the patient to clinical management, not simply to screening.
- When the study answers a mammographic finding, issue the combined assessment — the final BI-RADS category belongs to the complete workup, not each modality separately.
Frequently asked questions
What should a targeted breast ultrasound report document?
A targeted diagnostic breast ultrasound report documents exactly what was scanned — the clock-face position, distance from the nipple and correlation with the palpable or mammographic finding — plus the findings at that site, the skin, and the imaged axilla. A normal study states there is no solid or cystic mass, architectural distortion or abnormal shadowing at the site of concern, with a BI-RADS category 1 assessment. Precise location documentation protects everyone if a cancer later appears there.
Does a negative breast ultrasound rule out cancer in a palpable lump?
No. A negative targeted ultrasound lowers suspicion but does not by itself dismiss a clinically suspicious palpable finding. The recommendation should return the patient to clinical management of the palpable abnormality — surgical consultation or biopsy if clinical suspicion persists — rather than simply to routine screening. Imaging and clinical assessment are complementary, and the report wording should keep the clinical pathway open.
How is the BI-RADS category assigned when ultrasound answers a mammographic finding?
The final BI-RADS assessment belongs to the complete diagnostic workup, not to each modality separately. When a targeted ultrasound is performed to evaluate a mammographic finding, the report should issue a combined assessment that integrates both examinations — one category and one recommendation. Issuing separate, potentially conflicting categories for the mammogram and the ultrasound leaves the referring clinician without a single actionable answer.
MyRadAgent turns a scratch dictation into this report — structured, guideline-checked, in your own section headers and phrasing. It learns your style from every correction. Free trial: 100 reports over 14 days, no card, no IT ticket.
Draft a report with it → or watch the live demo first — no signup →