Hauptbefunden

Hauptbefund is a term used in German medical reporting to designate the main findings of an examination. It refers to the most clinically relevant results that guide diagnosis and treatment. The Hauptbefund is typically concise and written to communicate the essential information quickly to the referring physician, often serving as the core conclusion of the report.

In radiology, where the term is most common, the Hauptbefund is usually presented at the beginning of the report. It may appear as one or a few short sentences and is followed by details on technique, comparisons, and any accompanying Nebenbefunde. The Hauptbefund focuses on the findings that most directly impact patient management, while Nebenbefunde document secondary or incidental observations.

The content of a Hauptbefund describes the location, extent, and clinical significance of abnormalities, and may include qualifiers such as findings being definite, probable, or suspicious, as well as measurements when relevant. It should reflect the current examination and avoid unnecessary speculation about unrelated history.

Nebenbefunde are additional findings that are not the primary basis for immediate decisions. They are recorded to ensure a complete documentation of the examination but do not dictate the principal clinical conclusions. The Beurteilung (assessment) or Schlussbemerkung of the report usually provides differential diagnosis, recommended follow-up, or treatment implications, building on the Hauptbefund.

Variations exist across disciplines and institutions. Some settings use Hauptbefund less explicitly and rely on a combined Befund with an accompanying Beurteilung. Regardless of format, the Hauptbefund aims to present the key information necessary for clinical action.