The technical and interpretive skills of the physician–sonographer will be judged by peers, including radiologists and cardiologists, and potentially in a court of law if misinterpretations occur and adverse events result. The ultrasound report is an important tool for assuring that physicians document their findings on the data gathered, the interpretation of those data, their decision about what, if anything to do with the acquired information, and the actions, if any, that were taken for the patient’s benefit.
Reports should be constructed in such a manner as to provide the necessary information to those interested in understanding the procedure within the context of the patient’s condition. The report serves not only for documentation, but as a communication tool from one provider or group of providers to another.
This appendix includes several report templates that can be useful in assuring that the reports of intensive care unit (ICU) ultrasound procedures for different body regions contain the relevant information. Ultimately, each physician–sonographer will find his or her own method of relating findings in the chart to the patient’s family and to other medical professionals; however, the following examples provide a reasonable starting point.
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