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    This document provides an example worksheet for documenting routine ultrasound examinations. The worksheet includes sections for documenting patient information, examination details, measurements, anatomical findings, conclusions, and image documentation. Abnormal findings are marked with an asterisk and can be detailed in a designated section. The worksheet standardizes data collection for ultrasounds and allows clinicians to efficiently document examination results.

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    This document provides an example worksheet for documenting routine ultrasound examinations. The worksheet includes sections for documenting patient information, examination details, measurements, anatomical findings, conclusions, and image documentation. Abnormal findings are marked with an asterisk and can be detailed in a designated section. The worksheet standardizes data collection for ultrasounds and allows clinicians to efficiently document examination results.

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    6 views1 page

    ISUOG Practice Guidelines - Performance of Firsttrimester Fetal Ultrasound Scan

    Uploaded by

    sandrogvaladze
    This document provides an example worksheet for documenting routine ultrasound examinations. The worksheet includes sections for documenting patient information, examination details, measurements, anatomical findings, conclusions, and image documentation. Abnormal findings are marked with an asterisk and can be detailed in a designated section. The worksheet standardizes data collection for ultrasounds and allows clinicians to efficiently document examination results.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    ISUOG Guidelines 113

    APPENDIX: ROUTINE ULTRASOUND WORKSHEET (EXAMPLE)

    Patient: ID number: SONOGRAPHIC N Ab* NV


    APPEARANCE OF FETAL
    Date of birth (DD/MM/YYYY): ANATOMY:
    Referring physician: (N = Normal; Ab = Abnormal*;
    NV = Not visualized)
    Date of exam (DD/MM/YYYY): Gray = optional
    Sonographer / Supervisor: Head
    Indication for scan and relevant clinical information: Shape
    Cranial ossification
    LMP Midline falx
    Choroid plexus
    Technical conditions: Good / Limited by: Face
    Singleton / Multiple (use 1 sheet/fetus) Orbits
    => Chorionicity: Profile
    Neck
    ADNEXA:
    Thorax
    Appearance Normal Abnormal*
    Pulm. area
    Anomaly:
    Diaphragm
    MEASUREMENTS mm Centile (Reference range) Heart
    Crown–rump Heart activity
    length Size
    Nuchal Cardiac axis
    translucency (optional) Four-chamber view
    Biparietal diameter Abdomen
    Head Stomach
    circumference Bowel
    Abdominal Kidneys
    circumference Urinary bladder
    Femoral diaphysis Cord insertion /
    length abdominal wall
    *Abnormal findings (please detail): Cord vessels
    Spine
    Limbs
    Ultrasound-based estimate of GA: Right arm (incl. hand)
    Right leg (incl. foot)
    ………..weeks + ………..days Left arm (incl. hand)
    Left leg (incl. foot)
    Gender (optional): M F
    CONCLUSION: Other:
    Normal and complete examination.
    Normal but incomplete examination.
    Abnormal examination*
    Plans: No further ultrasound scans required
    Follow up planned in ….. weeks.
    Referred to ……………
    Produced Printed Stored
    Other:
    No. of images

    Copyright  2013 ISUOG. Published by John Wiley & Sons, Ltd. Ultrasound Obstet Gynecol 2013; 41: 102–113.

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