Normal Screening Mammogram Report Template (BI-RADS 1)
Normal bilateral screening mammogram report template with breast density statement, BI-RADS category 1 assessment and MQSA-compliant wording.
EXAMINATION: Bilateral screening mammogram with tomosynthesis. CLINICAL HISTORY: Screening. COMPARISON: [date of prior, or None available]. TECHNIQUE: Standard CC and MLO views of both breasts with digital breast tomosynthesis. FINDINGS: Breast composition: The breasts are [density category]. There is no suspicious mass, architectural distortion or suspicious grouped calcification in either breast. Skin and nipple-areolar complexes: Unremarkable. Axillae: No abnormal lymph node on the imaged portions. IMPRESSION: 1. Negative bilateral screening mammogram. BI-RADS Category 1 — Negative. RECOMMENDATION: Continue routine annual screening mammography.
Dictation notes
- The density statement and the BI-RADS category are MQSA audit items — both must appear verbatim, every time.
- A screening exam never carries BI-RADS 3; anything short of 1 or 2 is a recall (category 0).
Frequently asked questions
What must a screening mammogram report include under MQSA?
Every mammogram report must include a breast density statement using the BI-RADS composition categories and a final BI-RADS assessment category — both are audit items, and both must appear verbatim every time. A normal screening study is reported as BI-RADS Category 1 (Negative) with a recommendation to continue routine screening. The structured sections also cover comparison with priors, technique including tomosynthesis, and the imaged axillae.
Can BI-RADS 3 be assigned on a screening mammogram?
No. BI-RADS 3 (probably benign) is reserved for a finding that has been fully worked up with diagnostic imaging. On a screening examination the only appropriate assessments are category 1 or 2 for a negative or benign study, and category 0 — a recall for additional imaging — for anything else. Assigning category 3 directly from screening skips the diagnostic evaluation that justifies short-interval follow-up.
What do the BI-RADS breast density categories mean?
BI-RADS defines four composition categories: almost entirely fatty; scattered areas of fibroglandular density; heterogeneously dense, which may obscure small masses; and extremely dense, which lowers the sensitivity of mammography. The density statement is required in every report, and the two dense categories matter clinically because they reduce mammographic sensitivity and factor into supplemental-screening discussions, including eligibility conversations about ultrasound or MRI.
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