The following Templates of Ultrasound Structured Reports can be used and modified by individual practices:
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1 The following Templates of Ultrasound Structured Reports can be used and modified by individual practices: US Abdomen Complete (generic) Clinical History: [abdominal pain, fever, mass, etc] Study: [complete ultrasound of abdomen] Prior study: [none] Liver: size- [normal] [enlarged] [small] echogenicity- [normal] [hyperechoic consistent with hepatic steatosis] [heterogenous contour- [smooth] [nodular consistent with cirrhosis] [cyst measuring L x AP x W cm] [solid mass measuring L x AP x W cm]] bile ducts- [intrahepatic and extrahepatic bile ducts not dilated with common bile duct measuring.. mm] [intrahepatic bile ducts dilated] [extrahepatic bile duct dilated with common bile duct measuring..mm] Gallbladder: [normal] [cholelithiasis] [gallbladder wall thickened] [no pain over gallbladder] Pancreas: [head, body, and tail appeared normal] [head and body appear normal; tail obscured by bowel gas] Spleen: [normal measuring L x AP x W cm] Kidneys: [no pelvicalyceal dilatation with right kidney measuring cm in length; left kidney measuring cm in length] Aorta & Inferior vena cava: [visualized portions appear normal]
2 Ascites: [none] IMPRESSION: [ ] US Abdomen Complete (Normal) Clinical History: [abdominal pain, fever, mass, etc] Study: [complete ultrasound of abdomen] Prior study: [none] Liver: size- normal echogenicity- normal contour- smooth bile ducts- intrahepatic and extrahepatic bile ducts not dilated with common bile duct measuring.. mm Gallbladder: normal no pain over gallbladder Pancreas: head and body appear normal; tail obscured by bowel gas Spleen: normal measuring L x AP x W cm Kidneys: no pelvicalyceal dilatation with right kidney measuring cm in length; left kidney measuring cm in length Aorta & Inferior vena cava: visualized portions appear normal Ascites: [none] IMPRESSION: normal complete ultrasound of the abdomen
3 US Retroperitoneum Complete (generic non urinary tract indication) Clinical History: [mass, etc] Study: [complete ultrasound of retroperitoneum] Prior study: [none] Kidney: size- right measures L x AP x W cm; left measures L x AP x W cm echogenicity- [normal] [hyperechoic] parenchymal thickness- [normal] [thinned] contour- [smooth] [scarred] pelvicalyceal dilatation- [none] [mild, moderate, severe] calculus- [none] [nonobstructing measuring.mm] [cyst measuring cm] [solid measuring... cm] Aorta: [normal] [atherosclerotic] aneurysm- [none] [location- infrarenal, etc] [measures cm] IVC: [normal] [dilated suggesting heart disease] Bladder: [normal] [empty] IMPRESSION: [normal complete ultrasound of retroperitoneum]
4 US Retroperitoneum Complete (urinary tract indication-normal Study) (Since urinary tract indication do not need to evaluate aorta and IVC to code as Complete US of Retroperitoneum) Clinical History: [UTI, hematuria, etc] Study: [complete ultrasound of retroperitoneum] Prior study: [none] Kidney: Bladder: size- right measures L x AP x W cm; left measures L x AP x W cm echogenicity- [normal] parenchymal thickness- [normal] contour- smooth pelvicalyceal dilatation- none calculus- none normal IMPRESSION: normal ultrasound of kidneys and bladder US Pelvis Complete (Transabdominal or Transvaginal) Clinical History: [pelvic pain, vaginal bleeding, etc] [LMP: date] [pregnant: no or yes] [postmenopausal since date] Study: [transabdominal ultrasound of pelvis] [transvaginal ultrasound of pelvis] Uterus: orientation- [anteverted, retroverted] size- [L x AP x W cm] [solid measuring...cm including location] cervix- [normal] [nabothian cyst] endometrium- [normal] [endometrial thickness measures mm]
5 Ovaries: size- right measures L x AP x W cm; left measures L x AP x W cm [simple cyst measuring ] [complex cyst measuring ] [solid measuring...] Adnexa: [cyst measuring ] [solid measuring...] Cul-de-sac: [no free fluid] [small amount of free fluid] IMPRESSION: [ ] US Pelvis Complete (Normal Transvaginal US of Pelvis) Clinical History: pelvic pain LMP: date pregnant: no Study: transvaginal ultrasound of pelvis Uterus: orientation- anteverted size- [L x AP x W cm] cervix- normal endometrium- normal endometrial thickness measures mm Ovaries: size- right measures L x AP x W cm; left measures L x AP x W cm Adnexa: Cul-de-sac: no free fluid IMPRESSION: normal transvaginal ultrasound of the pelvis If both transabdominal and transvaginal ultrasounds of the pelvis are performed, some practices dictate the transabdominal examination of the pelvis first and then dictate the transvaginal examination. Others, dictate saying transabdominal
6 ultrasound of the pelvis was first performed; then transvaginal ultrasound was performed to further evaluate the pelvis and dictate one set of findings.
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