0:01

So, for report organization,

0:03

you want to make sure that you have an indication

0:05

that's very clear.

0:07

You know, why we're doing the exam.

0:08

If there's something to follow,

0:09

what are we following and what breast? You want to talk about

0:13

the MRI technique, what was the technique used?

0:16

And that can be a paragraph that's part of a template.

0:21

The description of the breast composition.

0:23

So that's the amount of fibroglandular tissue.

0:25

Description of the background parenchymal enhancement.

0:28

Describe any important findings with comparison

0:32

to prior exams, and then give the BI-RADS assessment

0:35

category and the management recommendation.

0:39

This is our basic template for reporting breast MRI.

0:44

We have a few different templates,

0:47

depending on whether it's negative or benign,

0:50

or we have some findings, but the basics are similar.

0:54

There's a history that sort of propagated from our

0:56

radiology information system

0:58

and sometimes has to be modified, but you know.

1:02

An x-year-old woman seen for whatever indication.

1:08

The last menstrual period.

1:10

What films were compared?

1:12

The technique, you know, ours has a drop down menu for

1:16

whether it's a 1.5 or 3 Tesla.

1:19

What technical factors were used,

1:21

you just pick those off.

1:23

And then how many times we did post contrast exams.

1:26

In our case, it would be 3 times here.

1:29

And how much contrast was given.

1:30

That's weight-based. So it's going to vary from patient to patient.

1:35

So, you know, how much contrast was used and what

1:38

type of contrast was used, so that's all recorded.

1:41

And then we have a recording of fibroglandular

1:44

tissue and background parenchymal tissue.

1:46

So there's a reminder to put those in.

1:48

And then sections for right and left breast and their findings.

1:52

No template for that.

1:54

That's really just a free dictation. And then,

1:59

our kinetic analysis statement and our impression

2:03

and recommendation, and then BI-RADS category.

2:06

So, this is the template that we're using. We pull that up.

2:09

And then we, you know, sort of fill it in

2:11

as needed in our radiology information system.

2:15

Here's an example

2:18

of a report.

2:19

The history is a 60 year old woman seen for high risk screening

2:24

and she has a strong family history of breast cancer.

2:26

She's postmenopausal,

2:27

we have our technique paragraph filled in here, and then

2:33

her findings in the right breast and the left breast,

2:37

you know, we say we've got some scattered foci of enhancement,

2:39

may be more prominent on the left than the right.

2:42

But similar to prior studies, nothing suspicious.

2:45

On the left, she has a biopsy clip,

2:49

Our kinetic analysis paragraph,

2:51

our impression, and recommendation,

2:53

which includes

2:55

when she should have her screening mammogram and

2:59

you know, that we're going to continue high risk

3:00

screening breast MRI, and our BI-RADS category.

3:05

Another patient.

3:07

This is 65 year old woman who's had a left breast cancer.

3:12

We mentioned when it was and how it was treated,

3:15

and that the patient is taking an aromatase inhibitor.

3:19

We have our films compared and technique sections.

3:22

And then we go on to our findings, our amount of tissue, the

3:27

enhancement pattern, and then right and left breast findings.

3:31

We've got more going on in the left because she had

3:34

a lumpectomy and radiation changes.

3:39

And then our impression,

3:41

you know, pretty brief. Post lumpectomy changes left breast.

3:44

No suspicious enhancement in either breast.

3:47

And our recommendation for

3:49

mammography, and MR, and our BI-RADS category.

3:55

So, basically, similar type of report for this patient.

4:00

A 50 year old, for high risk screening,

4:02

you know, some procedure history,

4:04

her family history of breast cancer.

4:06

Our films compared and technique sections, same as before.

4:10

And then our findings.

4:12

Amount of tissue and background parenchymal

4:15

enhancement. And then right breast and left breast separate.

4:19

Right breast had a 4mm

4:21

focus of enhancement that we're following.

4:23

So we give a series and image number.

4:26

The left breast also had a focus that we're following.

4:30

We gave the series and image number. If there's,

4:32

you know, really nothing else to report, we say that the lymph

4:36

nodes looked okay and, you know, the rest is similar.

4:40

Just these same templated headings. But we want

4:44

to make sure that we have a definite impression.

4:49

A definite recommendation for what we're going to do as far as

4:52

follow-up and then our BI-RADS category given at the end.