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Ultrasound Order Form - Department of Obstetrics and Gynecology

Ultrasound Order Form - Department of Obstetrics and Gynecology 2025

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The document is an ultrasound referral order form from Washington University, specifically for Maternal-Fetal Medicine and Ultrasound. It includes sections for patient information, insurance details, referring physician, preferred scan locations, and various ultrasound indications. The form outlines different types of ultrasounds and diagnostic tests available, along with a requirement for physician signature.

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Click ‘Get Form’ to open the Ultrasound Order Form in the editor.
Begin by entering the patient's name, date of birth, and contact information in the designated fields. Ensure all required fields are filled out accurately.
Indicate if an interpreter is needed by checking the appropriate box and specifying the language if applicable.
Fill in insurance details including the insurance name, policy holder's name, policy ID, and group number. This information is crucial for processing referrals.
Select the preferred scan location from the options provided. If applicable, indicate whether the patient is inpatient.
Specify the indication for referral by selecting from options such as Gynecologic or Obstetric Ultrasound and provide relevant details like LMP and EDC.
Complete any additional sections related to diagnostic testing or genetic counseling as necessary.
Finally, ensure that a physician signature is included along with the date before submitting the form.

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We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is an ultrasound order?

An ultrasound order, is essentially a prescription or referral from a healthcare provider requesting an ultrasound examination for a patient. This order outlines the medical necessity for the ultrasound procedure and provides pertinent information for the radiologist or sonographer performing the scan.

Can an obgyn order an ultrasound?

During pregnancy, your obstetrician will order or perform routine ultrasounds for a number of reasons, but they are done primarily to assess the growth and development of your baby.

How to write an obstetric ultrasound report?

The obstetric ultrasound report should include 3 essential components: basic information about the pregnancy, fetal biometric measurements and fetal anatomic details.

What are the documentation requirements for ultrasound guidance?

Ultrasound Guidance The documentation should clearly indicate the type of procedure, the specific anatomical location of the images, the specific anatomic structures visualized, and a documented description of the localization process. This information is critical to ensure that the service is accurately reported.