Radiology report template: Free download and 4-part guide

Key takeaways

A radiology report is the radiologist’s written answer to the question a referring clinician asked when ordering the study.

Four sections carry the report: clinical history, technique, findings, and impression, and each one answers a different question.

Structured templates cut ambiguous wording, stop required fields being skipped, and make the report easier to bill from.

Practice management software like Pabau turns the report into a form, stores it on the client record, and tells the referrer it is ready.

A radiology report template exists for one reason. The referring clinician has to find the answer fast. They open the report, jump straight to the impression, and decide what happens to the patient next. If that impression does not answer the question they asked, the study cost time without changing care.

Get the structure right and the report reads the same way every time, whoever dictated it. Below you get the free template, what each section owes the reader, and how a report moves from the scanner to the referrer’s inbox.

What a radiology report is, and who reads it

A radiology report is a radiologist’s written interpretation of an imaging study, addressed to the clinician who ordered it. It stands as the record of the exam, and it drives the next decision about treatment.

According to the Radiological Society of North America, the report is written for the referring clinician rather than for the patient.

When two people read the report in practice, the referrer reads the impression and acts on it, and months later, another clinician reads the findings to compare them against the next study. This is why measurements and locations earn their place.

Four sections carry the whole report

Every professional report follows the same four-part structure. Each section answers a different question, and each one fails in its own way.

The diagram below pairs each section with the question it owes the referrer, and with the error it tends to carry.

Clinical history and indication: Why the study was ordered

This section says why the imaging happened. Record the presenting symptom, the relevant history, any prior diagnosis, and the specific question the study has to settle.

Leave the field blank and the radiologist reads without context, which is how a technically correct report ends up answering the wrong question.

Technique: What produced the images

Name the modality, the equipment, and the protocol. Write it precisely enough that another radiologist could repeat the study. Multidetector CT with contrast, 3.0 Tesla MRI with and without gadolinium, and portable chest X-ray all work as phrasings. Record the contrast agent, the scanning parameters, and any change from your standard protocol.

Billing leans on this section too, because the code has to match what was performed. Contrast is the usual sticking point, so state whether it was given and by which route.

Findings: What the images actually show

Findings are observations, not conclusions. Describe what you see with precise anatomic terms and measurements, working through the study by region or organ system.

Note the normal structures alongside the abnormal ones, so the referrer knows what you examined. Keep hedging language out of here. “May represent” belongs in the impression, where interpretation lives.

Impression: What it means and what happens next

The impression answers the question from the history, in as few lines as it takes. State the diagnostic conclusion, the recommended follow-up, and any finding that needs a phone call rather than a report.

Nothing new belongs here. A lesion that appears in the impression but not in the findings makes the report contradict itself. The referrer then has to call you to sort it out.

Structured beats narrative for most imaging practices

Structured reporting wins for most practices, and the table shows where. Structured means the radiologist fills a template. Narrative means free text from a blank screen.

Hartung and colleagues make the same case in RadioGraphics. Structured reports read more consistently, and they leave less room for ambiguity than free text.

Narrative still has a place. An unusual case sometimes needs a paragraph that no template anticipated, so keep the option rather than forcing every study into fields.

Each modality needs its own fields

A CT report and an ultrasound report do not ask for the same information, so one generic form will not serve both. The RSNA runs RadReport, a library of templates written by radiologists for each modality and body region.

• CT: contrast timing, reconstruction algorithm, organ-specific findings, and quantitative measurements such as lesion size and density values.
• MRI: pulse sequences, field strength, contrast administration, signal intensity, and the soft-tissue findings those sequences reveal.
• X-ray: positioning, technical quality, and findings grouped by region, such as lungs, mediastinum, and costophrenic angles on a chest film.
• Ultrasound: transducer frequency, patient position, color Doppler flow, measurements, and the real-time observations the sonographer made.

If you report vascular studies, our Doppler ultrasound report carries the flow velocities and waveform fields a general form leaves out.

Structured client records keep each modality’s form beside the study it belongs to. Nobody hunts through a shared drive for the current version, and the wrong template stops turning up in finished reports.

RADS categories turn a finding into a recommendation

A RADS category tells the referrer what to do, not just what you saw. The American College of Radiology publishes these reporting and data systems for specific screening and diagnostic settings.

• BI-RADS (Breast Imaging Reporting and Data System): categories 0 to 6 for breast imaging findings and cancer risk.
• LI-RADS (Liver Imaging Reporting and Data System): categories for assessing hepatocellular carcinoma in cirrhotic livers.
• Lung-RADS (Lung CT Screening Reporting and Data System): categories for managing lung nodules in screening populations.
• PI-RADS (Prostate Imaging Reporting and Data System): scoring for prostate MRI findings and biopsy risk.
• TI-RADS (Thyroid Imaging Reporting and Data System): categories for thyroid ultrasound findings and biopsy recommendations.

Put the category in the impression, next to the finding it describes. A number on its own leaves the referrer guessing which lesion you meant, and that guess turns into a phone call.

How the report actually moves through a practice

The report is a workflow, not just a document. Here is the path it takes, and where practices lose time.

1. The order arrives. The referrer’s question and the indication have to travel with it, or the technologist starts the study blind.
2. The technologist runs the protocol. Dose, positioning, and any deviation get recorded while the patient is still on the table.
3. The radiologist reads and dictates. Prior studies need to be on screen, not in another system.
4. A draft waits unsigned. Reports stall here more than anywhere else, so somebody has to own the unsigned queue.
5. The report is signed. Date and credentials go on at the same moment, not later from memory.
6. Distribution goes out. The referrer gets it, and so does anyone else on the recipient list.
7. Critical findings get a call. Log who was told, when, and by what method.

Most of the delay sits at step four. Forms built for clinicians can mark the indication and technique as required, so a half-filled report never reaches the signing queue in the first place.

Step seven is the one that gets written down last, usually after the call has already happened. Give that conversation a structure and it survives an audit, and our SBAR report template works well for the handoff.

Run this check before you finalize

Seven questions, and the report is ready to sign. The same list sits on page two of the template, so you can tick it on paper if that suits your team better.

• Does the impression answer the clinical question from the history?
• Does every abnormal finding carry a measurement and a location?
• Is the findings section free of interpretation?
• Does the impression add any finding the findings section never described?
• Does each RADS category sit next to the finding it describes?
• Was every critical finding communicated directly, and is that call logged?
• Is the report signed and dated, with credentials shown?

One item deserves more than a checkbox. Communicate a critical finding as soon as possible, per your institution’s critical-results protocol. Use a phone call or a secure message rather than the report alone.

The ACR practice parameter on communicating imaging findings leaves the timing to local policy, so write yours down and hold to it.

Mistakes that send a report back

Three questions come up again and again from practices tightening their reporting.

Why did the referrer call about a report that reads perfectly well? Usually the impression answered a different question than the one in the history. Check the indication field first, before you re-read the images.

Why do our reports vary so much between radiologists? Free text lets each person pick an order and a vocabulary. A template removes that choice for the parts that should never vary, and leaves it where judgment belongs.

Why does billing keep querying our technique wording? The code has to match the study performed, contrast included. Vague technique wording forces a coder to guess, and a guess is what a payer queries.

How to adapt the template to your practice

1. Download the PDF and store it where your team already looks for forms, whether that is your records system or a shared folder.
2. Cut what you do not use. Delete the modality fields your practice never reports, and add the body regions you cover most.
3. Embed the RADS checklist that applies to your service. A breast screening practice adds BI-RADS categories directly into the impression field.
4. Train on the wording rules, not only the field order. Consistency is a habit, and it slips within weeks without a refresher.
5. Map the fields to your codes, so findings and impression feed the diagnosis and procedure codes your claims need.

Who this form is for

Any practice that documents imaging findings can use it. That covers diagnostic imaging centers, hospital radiology departments, and radiologists in private practice.

It also suits practices with imaging on the side of another service. Sports medicine practices with an in-house ultrasound, and occupational health services running on-site X-rays, need the same structure as a dedicated center.

What standardization actually buys you

Three changes show up once the template is in daily use. Dictation gets shorter, because the radiologist stops deciding what order to work in. Clarification calls drop, because the impression sits where the referrer expects it. Audit and claims data gets cleaner, because the same fields are filled every time.

An audit asks one question. Can you show the record? A form that fills the same fields on every study keeps that answer short, and keeps it the same answer whoever is asked.

How Pabau keeps radiology reports complete and delivered

Most imaging practices keep the report in one place, the patient’s history in another, and the referrer’s details in a third. The report gets finalized, then somebody emails it. Practice management software like Pabau, our all-in-one platform for clinical and business operations, holds all three in the same record.

Build the report as a digital form and every field the template asks for becomes a field the software asks for. Mark the indication and technique as required, and an incomplete report cannot reach the signing queue. The finished report attaches to the client record, beside the imaging request and the prior study.

Delivery runs on the same record. Automated messages tell the referrer the report is ready, and each send is logged against the patient. Your audit trail then stops depending on somebody’s sent-mail folder.

Pabau Scribe, our AI scribe, drafts the clinical note from the consultation, which leaves the radiologist writing the report instead of retyping the history.

Deliver complete radiology reports on time

Pabau turns your radiology report template into a digital form and stores each finished report on the client record. Automated messages tell the referring clinician it is ready.

Book a demo

Conclusion

The template is the easy part. Holding to it is what changes how your reports read. That takes two decisions. Set a rule about the indication field, and name an owner for the unsigned queue.

So start narrow. Keep the modality sections you actually report, delete the rest, and put the sign-off checklist where the team will see it. A form nobody can find gets replaced by free text within a month.

One trade-off is worth remembering. A template constrains the unusual case, so leave room for a paragraph where the reasoning needs it.

If your reports are finished on time but still arrive late, the problem is distribution rather than dictation. Book a demo to see how Pabau moves a signed radiology report to the referring clinician without a manual email.

Continue your research

Reporting vascular studies? The Doppler ultrasound report template adds the flow velocity and waveform fields a general imaging form leaves out.

Need a structure for the critical-findings call? The SBAR report template gives that conversation a shape an auditor can follow.

Documenting procedures as well as imaging? Our operation notes template covers the fields a surgical record needs, from indication to post-operative plan.

Tracking a patient across visits? The clinical progress notes template keeps each follow-up entry consistent enough to compare month to month.

Moving off paper forms? Our guide to clinical documentation software explains what to look for before you commit a practice to one system.

Frequently asked questions