Appendix B: DRAFT ULTRASOUND REPORTS BY BODY REGION

Introduction

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.

• Ultrasound of the neck or larynx

  1. General information

     1. State the indication for the examination (e.g., neck mapping prior to percutaneous tracheostomy or evaluation of endotracheal tube (ETT) placement)

     2. Provide patient identifying information (name, age, and medical record number)

     3. Time the beginning and the end of the examination

  2. Specific information

     1. Report your findings

     2. Begin with an overall assessment of the technical quality of the study. For example, were all views obtained? Can all the appropriate structures be visualized? Is the study adequate to answer the clinical question?

     3. The physician should pay particular attention to the stated reason for the examination. The examination details should be described including the anatomic or physiologic findings. For example, the neck was mapped prior to percutaneous tracheostomy. There was a bridging anterior jugular vein at the level of the second tracheal cartilage, and a midline inferior thyroid artery, visualized in transverse and longitudinal views, with two-dimensional and color Doppler. A suitable window for the puncture was located in between the second and third tracheal ring, and the site was marked on the skin

     4. For neck mapping prior to tracheostomy, make note of the tracheal anatomy itself, such as the number of tracheal rings visible superior to the sternal notch, the width of the trachea at the proposed insertion site, which may impact the size of the inserted tube, and the angle that the trachea makes with the skin surface (e.g., parallel vs. “diving”)

     5. Examine the entire trachea for overlying vascular structures, paying particular attention to any aberrant thyroid vessels or bridging jugular vessels. Note the depth of the trachea from the skin

     6. For ETT placement, assure that the tip is in the trachea and not the esophagus. If the tip is seen, note its distance from the ...