Ultrasound worksheet form 2025

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  1. Click ‘Get Form’ to open the ultrasound worksheet in our editor.
  2. Begin by entering the 'Patient Name' and 'Date of Exam' at the top of the form. This information is crucial for identifying the patient and tracking their medical history.
  3. In the 'History' section, provide relevant medical history that may impact the ultrasound results. This helps healthcare providers understand the context of the exam.
  4. Fill in measurements for 'Trans Abdominal' and 'Trans Vaginal' sections. Use the provided fields to input dimensions accurately, ensuring you follow any specific measurement guidelines.
  5. Document any fibroids or cysts by entering their sizes in the designated fields. Be thorough, as this information is vital for diagnosis.
  6. Complete the 'Doppler Flow' section by indicating whether arterial and venous waveforms are present, using checkboxes for clarity.
  7. Finally, add any comments in the designated area and ensure that both 'Sonographer' and 'Physician Notified' sections are filled out appropriately before saving your work.

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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.
Patient characteristics and identifiers, such as her name, identification numbers, age or preferably date of birth, gravity and parity and date of last menstrual period are important components of the ultrasound report and should be included in its top section and easily identified.
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. (8)
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Ultrasound Documentation Requirements The minimum documentation required by CPT is a separate summarized written paragraph documented in the patients chart with any permanently recorded images (with measurements when clinically indicated) and all anatomic areas imaged must be described.
When describing the image, we usually use the relative echogenicity of certain areas to characterize them. For example, if you want to specify the renal pelvis (blue arrows), you would write that there is a hyperechoic area in the mid-field surrounded by hypoechoic renal parenchyma.
There should be a permanent record of the ultrasound examination and its interpretation. Comparison with prior relevant imaging studies may prove helpful. Images of all appropriate areas, both normal and abnormal, should be recorded. Variations from normal size should generally be accompanied by measurements.

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