ultrasound exam patient report

What is an ultrasound report?

An ultrasound report is a formal document and represents an important waypoint on the management pathway of the patient.

What should be included in the final report of ultrasound findings?

A signed final report of the ultrasound findings is included in the patient’s medical record and is the definitive documentation of the study. The final report should include but is not limited to the following: • Patient’s name and other identifying information. • Name of patient’s health care provider.

How do you write a good ultrasound report?

The ultrasound report needs to strike a balance between conciseness and sufficient clinical detail. 32, 44, 57, 58 The sonographer should have a thorough understanding of what information is relevant to the referring clinician and tailor the report accordingly by prioritising clinically important observations.

What is an ultrasound examination?

Unlike other radiology scans, an ultrasound examination involves important elements of clinical interaction between the sonographer and the patient such as history‐taking, observation, palpation, dynamic assessment using various manoeuvres, sonopalpation and assessment in different body positions. It is a comprehensive examination, not a scan.

How do I report ultrasound findings?

Report structure(1) Title.(2) Patient identification, demographics, date, recipients, provider details.(3) Indications: history and clinical information.(4) Technique and procedural description (when required)(5) Findings. ... (6) Impression/Conclusion.(7) Names of the individuals involved in the examination.More items...•

Will sonographer tell you results?

The results of the ultrasound scan are usually sent to your doctor, so you will have to make a follow-up appointment with them to get the results.

Does a sonographer write the report?

The sonographer works with a reporting physician, such as a radiologist or other qualified specialist physician, who has responsibility for supervising the examination, reading and interpreting the results and providing the final report to the referring practitioner.

What makes a good ultrasound report?

There is no single 'correct' way to report, but important elements include a concise, logical structure, clarity, accuracy and an attempt to answer the clinical question, with differential diagnoses if appropriate, and suggestions for further management.

Will ultrasound tech tell me if something is wrong?

If your ultrasound is being performed by a technician, the technician most likely will not be allowed to tell you what the results mean. In that case, you will have to wait for your doctor to examine the images. Ultrasounds are used during pregnancy to measure the fetus and rule out or confirm suspected problems.

How long does it take to get an ultrasound report?

An ultrasound test usually takes 30 minutes to an hour. If you have any questions about your specific type of ultrasound, ask your healthcare provider.

What is a preliminary ultrasound report?

The preliminary report must contain the patient's identifying information, requesting provider's informa- tion, interpreting provider's contact information, pertinent clinical information, date and time of the ultra- sound examination, and specific ultrasound examination performed.

What is the difference between ultrasound and sonography?

The difference between sonogram and ultrasound An ultrasound is a tool used to take a picture. A sonogram is the picture that the ultrasound generates. Sonography is the use of an ultrasound tool for diagnostic purposes.

What kind of writing do Sonographers do?

Consider your audience and write in a way that they can understand you. There are three main types of articles that the Journal of Diagnostic Medical Sonography publishes that are a good place for a sonographer to start: case studies, literature reviews and original articles.

What abnormalities can be detected on an ultrasound?

Major anomalies that can be identified include anencephaly (absent skull and brain; Figure 1), acrania (absent skull), and holoprosencephaly (no division into separate hemispheres, with absence of midline structures; Figure 2).

How do you read ultrasound pictures?

To read an ultrasound picture, look for white spots on the image to see solid tissues, like bones, and dark spots on the image to see fluid-filled tissues, like the amniotic fluid in the uterus.

What should be included in an ultrasound report?

13, 22, 23, 25, 29 - 31 In general, an ultrasound report should contain the following sections: (1) Title. (2) Patient identification, demographics, date, recipients, provider details. (3) Indications: history and clinical information.

What is ultrasound examination?

Unlike other radiology scans, an ultrasound examination involves important elements of clinical interaction between the sonographer and the patient such as history-taking, observation, palpation, dynamic assessment using various manoeuvres, sonopalpation and assessment in different body positions.

What is the role of a sonographer in ultrasound?

Apart from the performance of the ultrasound scan, sonographers also have the ability to clinically examine the patient with the transducer (sonopalpation) and observe important physiological or pathological changes with various clinical manoeuvres or in different patient positions.

Why should sonographers use consistent terminology?

Whenever possible, sonographers should use consistent terminology to describe the same finding in different patients and the same finding in the same patient on follow-up examinations. Inconsistency in description can be difficult for the referring physicians to interpret.

What can a sonographer do?

A sonographer working in regional or tertiary-level centres may also be able to obtain valuable medical history from other sources including electronic records (admission and discharge summaries, clinic letters, surgical reports, laboratory tests, past imaging investigations) as well as hard-copy notes.

How long does it take to repeat a pelvic ultrasound?

Repeat ultrasound in 1 weeks’ time is recommended in order to complete fetal morphology assessment. Adequate transabdominal and transvaginal ultrasound examinations of the pelvis cannot be achieved because the patient is experiencing severe pain and cannot tolerate the examination. The examination was abandoned.

What is a graphic report?

Graphical reports include supplementary diagrams to better communicate the findings of the ultrasound examination. These types of reports have been commonly used in vascular laboratories because vascular surgeons show a strong preference for diagrams rather than plain text 34 (Figure 6 ). Another type of graphical report that may become more widespread in the future is the image-rich radiology report. Such a report contains a selection of images with annotations. 72

What do you start with in an ultrasound?

Discipline yourself to always use the same sequence of describing your findings. In abdominal ultrasound you might want to start with the liver then the gallbladder followed by the pancreas. In echocardiography I always start with the ventricles (left then right) then the atria followed by the valves etc.

What fonts are easy to read?

Example of fonts, which are difficult to read and should be avoided. Stick to fonts such as: Helvetica, Georgia, Verdana or Cambria. These fonts are among the easiest to read and also symbolize trust and authority. Example of fonts, which are easy to read and symbolize “authority”.

Can you print out images from a structured report?

Several structured reporting systems allow you to select images that are included in your report. If you do not have this feature, simply print out some images from your scanner. True, you will need to put some effort into creating a good report, but it pays off - for you and your patients.

Do doctors read the bottom of their reports?

Many physicians (including myself) often read the report from the bottom to the top, starting with the conclusion. We need to first get an overview before we dig into the details. Unfortunately many reports do not include a conclusion or do not provide the information I am looking for.

What are the advantages of ultrasound?

Advantages of ultrasound include detailed, real time, dynamic assessment of soft tissues and the ability to compare with the contralateral side.

What planes should a tear be measured in?

Type, size and location of tears is important, and measurements of full thickness tears should be made in two planes – anterior to posterior (transverse) and medial to lateral (longitudinal). The site of the tear measured from the rotator interval is also useful. Site of supraspinatus tendon tears .

Can ovarian ultrasound diagnose PCOs?

In patients with irregular menstrual cycles and hyperandrogenism, an ovarian ultrasound is not necessary for PCOS diagnosis; however, ultrasound will identify the complete PCOS phenotype. SCoR/BMUS Guidelines for Professional Ultrasound Practice. Revision 4, December 2019 64 .

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