REPORTING GUIDELINES (updated 1/30/19)
- This is for history that the technologist obtains in addition to what is stated on the requisition. Do not re type the history that is already provided on the order, as we see it anyway and it automatically populates our reports. So if the RUQ U/S history is “Pain r/o cholecystitis”, just leave additional history as “None” unless there’s relevant additional information, like “Patient reports cholecystectomy in 1998”. This saves time and eliminates redundancy. We very much appreciate any additional history but this is not always available or necessary.
- Pelvic ultrasound additional histories have “LMP” listed by default, so you can type in the LMP after it. If postmenopausal, state it in place of “LMP”, not after it.
- Comparisons. You should only list the relevant comparison exam(s) that you used to do the study. i.e. you see a liver mass on U/S and so you looked at the prior CT to see it was a hemangioma, so list the CT as the comparison. Or you see a DVT and compared to the prior leg ultrasound to see if it is acute. You may need to refer to multiple priors, but only list the relevant exams in which you needed to refer to.
- Report comparison exams in the following format: "CT abd/pel 1/5/2019".
- Ensure that techniques reflect what was done. i.e. pelvic ultrasounds - if transvaginal exam was not performed, be sure to change the default to transabdominal only, then state the reason in the comments (such as "patient declined transvaginal examination.")
- Pay attention to “cm” vs “mm” in the report templates. Most measurements are reported in cm but some (like the CBD) are mm.
- Use leading zeros for cm measurements which are less than 1 cm. i.e. report "0.6 cm" and not ".6 cm"
- Velocities should be rounded to the nearest cm/s (i.e. "76 cm/s", not "76.4 cm/s").
- Size measurements should be reported to the nearest millimeter. Do not report smaller than the nearest mm (i.e. “5.6 cm” not “5.58 cm”, CBD “5 mm” not “4.7 mm”. “5.58 cm” implies a level of precision that is not accurate.).
- Round numbers appropriately. i.e. CBD 4.5 mm rounds to 5 mm. CBD 4.4 mm rounds to 4 mm.
- 3 measurements and suffixes should be reported separated by spaces for clarity. i.e. “1.7 x 1.4 x 1.6 cm”.
- Avoid abbreviations to the extent possible. There is a lot of variability with use of abbreviations which becomes confusing and contributes to errors. i.e. use "Right" instead of "rt" or "rght" or "R"
- Use complete descriptive language when possible, as shorthand is extremely variably amongst different techs at many sites and leads to potential errors. i.e. Instead of "UP hypo ?comp cyst ?mass - 1.7cm", please state "1.7 cm hypoechoic right upper pole renal nodule, possible complicated cyst or solid mass.”
- First trimester OB - when a fetal pole is visible, use CRL for gestational age (most accurate). Do not use MSD or composite once a fetal pole can be reliable measured.
- If you report a finding, please remove the word "Normal." and put your finding(s) in its place.
- DVT ultrasounds with incidental inguinal lymph nodes. Consider morphology before calling a lymph node enlarged. Inguinal nodes with a diffusely thin cortex, reniform shape, with preserved hilum are likely normal.
- Simple follicles in reproductive age females measuring less than 3 cm are normal.
- Corpus luteums in reproductive age females measuring less than 3 cm are normal (diffusely thick wall, peripheral blood flow, +/- internal echoes, +/- crenulated appearance).
- "Comments:" should be used to convey additional information not otherwise listed in the standard findings template. i.e. "Comments: limited exam due to body habitus and patient motion." Or "Comments: Small right pleural effusion."
SONOGRAPHER PRELIMINARY ASSESSMENT
- State your assessment following "SONOGRAPHER PRELIMINARY ASSESSMENT: ", not elsewhere including the "Comments" section.
- ALL exams require a sonographer preliminary assessment. For normal exams, you can simple type "Normal, "Neg", "No DVT", etc.
- The preliminary assessment should include 1) what answers the clinical question, and 2) any important additional findings. For example, "No cholecystitis. 2 cm solid right renal mass." is an appropriate assessment.
- Additional incidental findings of little to no clinical concern do not need to be in the assessment but should be reported in the observations (i.e. simple renal cysts, ovarian follicles in premenopausal women, etc). This improves clarity but also saves you time, as many sonographers list all the findings again in the assessment.
- Try to avoid using "As above" as the preliminary assessment unless appropriate. An appropriate time to use "As above" is for carotid ultrasounds where sonographers report the measurements but do not grade stenoses. For negative cases, please say "Negative" or "Normal" in the assessment, not "As above."