Reporting and Documentation of Obstetric Ultrasound Scans

Introduction

An ultrasound scan report serves as a critical communication tool between the operator and various stakeholders, including patients and referring clinicians. It is generally expected that the individual performing the scan will also generate the report. These reports typically address specific clinical questions, and obstetric ultrasound is no exception. Both clinicians and patients anticipate clear, concise, and accurate reports, which should follow a logical structure, include differential diagnoses where applicable, and provide recommendations for further management. Despite the existence of model reporting templates developed by various national and international ultrasound societies, no universal consensus exists for all scenarios. Nonetheless, the need for reliable documentation of ultrasound examinations is indisputable, and representative images should be recorded in a retrievable format. The duration of storage for these images and reports should align with clinical needs and comply with relevant legal and local policies.

Publikationsverlauf

Artikel online veröffentlicht:
14. Oktober 2024

• Suggested Reading

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• 5 The ACOG & AIUM Practice Bulletin Number 175,. December 2016