关键词: 超声, 结构化报告, 住院医师, 规范化培训, 报告书写

Abstract: The ultrasound diagnosis imaging report reflects the sum of a radiologist's synthesis and judgement into a patient's condition. It is also an important product that is generated by radiologists to help the patients. In spite of the importance of clear and effective report writing, radiologists usually receive little or no formal reporting education. There are key principles when reporting the ultrasound findings, impression, and recommendations to promote report quality and reading experience. The findings should emphasize short and factual observations while avoiding redundancy. The impression is the thoughtful synthesis of findings leading to a diagnosis, a differential diagnosis and management recommendations. Improved report writing is achieved only after persistent learning, follow up and summaries.

Key words: ultrasound, structured reporting, resident, standardized training, report writing