In the field of veterinary medicine, precise and clear clinical documentation is crucial for effective patient care and communication. One common type of documentation is the X-ray report, which requires careful attention to detail and a standardized format to ensure all relevant findings are accurately recorded. In this guide, we will walk through the correct way to write and format an X-ray report using the RADS template, focusing specifically on the veterinary specialty.

When documenting an X-ray examination, it’s essential to follow a structured approach. The RADS template provides a comprehensive framework for capturing all necessary details. Below, we break down each section of the template, using specific examples to illustrate correct documentation practices.

Thoracic Examination

Begin with the thoracic region, assessing key structures:

• Extra-thoracic Structures: Document any abnormalities in skeletal and subcutaneous structures. For instance, "No significant abnormalities, skeletal and subcutaneous structures normal."

• Diaphragm: Ensure it is intact. Example: "Diaphragm: Intact."

• Pleural Space: Check for air or fluid. Example: "No air or fluid."

• Large Airways: Evaluate for normalcy. Example: "Normal, normal dorsal tracheal membrane."

• Pulmonary: Note any pathological patterns. Example: "No pathological pulmonary pattern present."

• Cardiac: Assess size and outline. Example: "Normal size and outline."

• Oesophageal: Look for air or foreign bodies. Example: "No air or foreign body present."

Abdominal Examination

Continue with the abdominal region:

• Extra-abdominal Structures: Identify any abnormalities. Example: "No significant abnormalities."

• Serosal Detail: Ensure clarity. Example: "Good."

• Liver/Spleen: Evaluate size and outline. Example: "Normal size and outline."

• Gastrointestinal Tract (GIT): Look for foreign bodies or gas dilation. Example: "No obvious radiopaque foreign body, or intestinal gas dilation."

• Kidneys: Assess visibility and presence of renoliths. Example: "Left: normal size and outline; Right: difficult to visualise completely; No obvious renoliths."

• Bladder/Prostate: Check for presence and uroliths. Example: "Bladder present, no obvious radiopaque uroliths."

Interpretation

Summarize the findings in a concise interpretation. For example: "The radiographic examination reveals no significant abnormalities in the thoracic and abdominal regions. The cardiac silhouette is of normal size and outline, and there are no signs of pathological pulmonary patterns. The liver, spleen, and kidneys appear normal, with no evidence of renoliths or uroliths. Overall, the findings suggest a healthy thoracic and abdominal status."

While accurate documentation is vital, it can also be time-consuming. This is where AI medical scribes like Notis AI Medical Scribe come into play, offering significant improvements in efficiency and accuracy for veterinary professionals.

Notis AI Medical Scribe leverages advanced voice-to-text technology to transcribe veterinary consultations into structured SOAP (Subjective, Objective, Assessment, Plan) notes, reducing documentation time by up to 80%. This allows veterinarians to focus more on patient care rather than administrative tasks.

Benefits for Veterinary Practices

Notis operates seamlessly through WhatsApp, ensuring ease of use with no need for additional software. With high accuracy in transcription and multilingual support, it caters to diverse veterinary practices. The AI system also provides comprehensive documentation capabilities, allowing for efficient storage and retrieval of patient records.

By integrating Notis into veterinary practice, professionals can enhance their workflow, reduce burnout, and improve the quality of patient care. The use of AI medical scribes represents a significant step forward in veterinary medicine, enabling veterinarians to meet the demands of modern clinical documentation with greater ease and precision.