Mammography reporting software with BI-RADS-structured templates

Mammography reporting software structures each report around breast composition, findings for each breast, comparison with previous studies and a final assessment category — commonly the BI-RADS categories 0 to 6. Caresoft RIS lets the department keep that structure as templates, highlight the category in the impression, sign digitally and deliver the report as a PDF.

A consistent structure

A mammography template in Caresoft RIS can carry clinical indication, technique (views), breast composition, findings for the right and left breast, comparison, and the impression with the assessment category highlighted so it stands out on the printed page. Many centres keep a companion breast ultrasound template for combined reports.

BI-RADS categories in the impression

Departments using BI-RADS can keep the categories in the template text — 0 incomplete, 1 negative, 2 benign, 3 probably benign, 4 suspicious, 5 highly suggestive of malignancy, 6 known biopsy-proven malignancy — together with the recommendation that goes with each. Caresoft RIS treats them as report text; it does not calculate categories.

Previous reports at hand

Screening is about comparison. The reporting screen lists the patient's earlier finalized reports, and the complete patient file can be printed or downloaded as one PDF.

Only users the administrator allows can finalize. A signed report cannot be overwritten; changing it needs a written reason and creates a new version, with the full history kept. Only one person can edit a draft at a time — anyone else who opens it sees it read-only and is told who is editing. Every finalize, amendment, print, PDF download and send is recorded.

Questions

Does Caresoft RIS assign the BI-RADS category automatically?

No. The radiologist chooses the category; templates simply keep the wording and layout consistent.

Can a combined mammography and breast ultrasound report be made?

Yes. Keep a combined template, or report the two studies separately; both stay in the patient file.