Report forms: each report in its own shape

Ultrasonography, X-ray, CT, MRI, ECG and echo reports each on their own form — the starters, the measurements, and forms the AI makes from sample reports.

An ECG report and an abdominal ultrasound report are shaped differently. A report form holds one kind of report’s own title, technique, measurements, sections in order (liver, gallbladder, kidneys…), impression and suggestion. A test given a form is written on that form and printed in that shape.

The starters

Ready for the centre: ultrasonography of the whole abdomen, KUB, lower abdomen, KUB with prostate, breasts and thyroid; X-ray of the chest, KUB, lumbosacral spine and knee; CT of the brain and HRCT chest; MRI of the brain and lumbosacral spine; ECG; and echocardiography. Each carries the usual normal wording.

A starter is a draft: until a doctor here has read it, the report screen says so. Change what your centre writes differently; a doctor who approves results can press I have read this form right on the report screen.

Open Report forms in Tests and prices — every form, by kind.
Open a form and change its name, printed title (with the Bangla), technique, measurements (with units), sections and their normal wording, impression and suggestion. Press Save.
Open the test in the test list and choose its Report form. With none chosen, it keeps the three boxes: findings, impression and comment.

Writing the report

A report on a form starts with its measurements, then each section with its normal wording — change only what is different. Every box can be dictated. Beside a measurement the normal range for the patient’s sex shows, where the form names its published source (the echo measurements: ASE/EACVI 2015).

On an ECG, with the QT and the heart rate written, the QTc (Bazett) is worked out and offered beside its box; it goes in only when you press Use. Nothing is put in by itself; check it.

The printed report has the form’s title, technique, a table of measurements (with the normal ranges), the sections, impression and suggestion — headings in Bangla on a Bangla report, the doctor’s words as written. Reports reach doctors’ apps and the PACS as before.

Exercise test and obstetric ultrasonography

The ETT (Bruce protocol) form holds the resting and peak heart rate and blood pressure, the duration, METs, why it stopped, and a table of the stages — each stage’s speed and grade already written; write the time, heart rate, blood pressure, ST change and symptoms, and add rows if needed. From the patient’s age the target heart rate (85% of 220 − age) and the peak as a percentage of it are offered beside their boxes.

On the obstetric ultrasonography form, with the BPD, HC, AC and FL written in millimetres, the gestational age (Hadlock 1984), the estimated fetal weight (Hadlock 1985) and the expected date of delivery are worked out and offered beside their boxes, with their source. They go in only when the sonologist presses Use, and can be changed after.

These are offers only; what goes on the report is the sonologist’s or cardiologist’s own decision.

Key pictures on the report

A written report (ultrasonography, X-ray, ECG, echo, ETT…) can carry up to four key pictures — a key frame, an ECG’s tracing — each with a short caption if you like. Press Add pictures on the report screen; each is made smaller on this computer before it is sent. On the printed report the pictures sit under the words, two to a row, or the full width when there is one.

Only the doctor writing the report can add or remove pictures, and once the report is approved its pictures are as fixed as its words — amend it, saying why, to change them. Each one added or removed is written in the log.

Culture, histopathology and cytology

The urine, blood, pus, sputum and stool culture forms hold the specimen and the antibiotics the laboratory tests — the list is the laboratory’s to set. On the report choose Growth or No growth; for a growth, the organism (the usual names come up as you type), the colony count, and each antibiotic’s MIC and S, I or R. Up to three organisms. The printed report sets the antibiotics in two columns.

The histopathology, Pap smear and FNAC forms hold the laboratory number and the sections in order; the diagnosis starts empty — the pathologist writes it. These laboratory tests are given their forms in the test list too.

Forms from sample reports (AI)

In Report forms, press Make forms from sample reports (AI).
Choose reports: up to 10 at a time, photos or PDFs (up to 2 MB) — your own or another centre’s. The cost in credits shows first.
Press Read them. They are read one by one; a page that is not a written diagnostic report is said to be so.
Read and keep: the draft opens beside its sample. Read it against the sample, change it, press Save. Nothing is kept unless you keep it.

Where a sample describes the patient’s abnormality, that section gets the usual normal wording instead and is named separately — read it first. The patient’s name, numbers, dates, doctors, and another centre’s name and logo are never taken into the form; the pictures are not kept either. Cover the patient’s name before you photograph if you can.

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