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Normal Diagnostic Mammogram with Targeted Ultrasound Report Template (BI-RADS 1)
Normal diagnostic mammogram with targeted breast ultrasound report template: the standard combined report with indication, breast density, mammographic findings at the area of concern, targeted ultrasound by clock position and distance from nipple, a single overall BI-RADS 1 assessment and MQSA-compliant recommendation.
EXAMINATION: [Right / Left / Bilateral] diagnostic mammogram with tomosynthesis and targeted [right / left] breast ultrasound. CLINICAL HISTORY: [indication, e.g. “Palpable lump, right breast, 10 o'clock, patient-reported for 3 weeks” / “Focal right breast pain” / “Recall from screening mammogram for possible asymmetry”] COMPARISON: [Screening mammogram dated x. / None available.] TECHNIQUE: Standard CC and MLO views of the [right / left / both] breast(s) with digital breast tomosynthesis, [spot compression / spot compression magnification] views of the [right / left] breast at the area of concern. A radiopaque marker was placed over the palpable abnormality. Targeted grayscale and color Doppler ultrasound of the [right / left] breast was performed at the site of clinical concern [and the corresponding axilla]. FINDINGS: Breast composition: The breasts are [a. almost entirely fatty / b. scattered areas of fibroglandular density / c. heterogeneously dense, which may obscure small masses / d. extremely dense, which lowers the sensitivity of mammography]. Mammogram: The marker overlying the palpable abnormality in the [right] breast at [10] o'clock projects over [normal fibroglandular tissue / fatty tissue] without an underlying mass, architectural distortion or suspicious calcification on the spot compression and tomosynthesis images. [The asymmetry seen on the screening study effaces with spot compression, consistent with overlapping normal tissue.] No suspicious mass, architectural distortion or suspicious grouped calcification elsewhere in [either / the] breast. Skin and nipple-areolar complex: Unremarkable. Axilla: No abnormal lymph node on the imaged portion. Targeted ultrasound: At the site of the palpable abnormality in the [right] breast at [10] o'clock, [x] cm from the nipple, there is [normal fibroglandular tissue / a prominent fat lobule] without a discrete solid or cystic mass, shadowing or distortion. The surrounding breast tissue is unremarkable. [Normal-appearing right axillary lymph nodes with preserved fatty hila, cortical thickness less than 3 mm.] IMPRESSION: 1. No mammographic or sonographic evidence of malignancy at the site of the palpable abnormality in the [right] breast at [10] o'clock. The clinical finding corresponds to normal fibroglandular tissue. 2. No suspicious finding elsewhere in [either / the] breast. BI-RADS Category 1 — Negative. RECOMMENDATION: [Return to annual screening mammography. / Clinical follow-up of the palpable finding; a palpable abnormality that is suspicious on examination warrants surgical consultation despite negative imaging.] The results and recommendations were discussed with the patient at the time of the examination.
Dictation notes
- One combined report carries one overall BI-RADS assessment: the mammogram and the targeted ultrasound are each described, then the highest category of the two is the final assessment — never a BI-RADS 1 mammogram sitting beside a BI-RADS 3 ultrasound in the same impression.
- Locate the ultrasound finding in three coordinates every time: clock position, distance from the nipple in centimetres and, for a mass, depth (anterior, middle, posterior third) — the biopsy and the surgeon's incision are planned from this line.
- State explicitly that the ultrasound was performed at the site of the clinical concern and what it showed there, even when normal; a negative imaging workup of a palpable lump has a small residual cancer rate, and the recommendation must say that a clinically suspicious finding is still referred.
- A diagnostic study may be BI-RADS 3 (probably benign, 6-month follow-up) but only after a complete workup; the screening recall that resolves as overlapping tissue on spot compression is BI-RADS 1 and returns to annual screening.
- The density statement, the overall BI-RADS category with its phrase and the documented discussion with the patient are MQSA audit items; the lay-letter category must match the report.
Related references
How to dictate a screening mammogram
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