Chapter 9 Documentation and Reporting

This course is about point-of-care ultrasound, or bedside ultrasound, done for a specific purpose in expediting clinical decisions. In providing standard ultrasound, there are typically at least two separate individuals involved – the woman’s provider and the one performing the ultrasound. This requires critical communication between these providers.

With point-of-care ultrasound, it may be presumed that the referring provider, the person scanning, and the provider who ultimately decides on a care plan, are all the same person. Because of that presumption, it is easy to think that documentation can be skipped or minimal. However, it is just as critical to provide all the information possible, especially since the burden of clinical decision-making and care management depends on the scanner, who must justify the assessment and subsequent plan. It is even more critical if referral to another provider is made, so that complete information can be sent.

Chapter 9 reviews general guidelines for documenting a standard ultrasound exam, as well as essential components of documenting for point-of-care ultrasound. There is much overlap between the two, but there are fewer detail components with a POCUS since typically fewer structures are being viewed.

Chapter 9: Objectives

By the completion of this Section, the participant will be able to:
List the essential components of documentation for any ultrasound exam performed
Describe the importance of text annotation on an image and how that can impact clinical management
Define a “critical finding” and the importance of obtaining consultation or referral in those cases
Review a report generated by a radiologist and locate critical findings

Point-of-care ultrasounds, especially in obstetrics and gynecology, are often done under conditions of urgency. This makes it a challenge for those performing POCUS exams to take time to accurately document in a meaningful manner. A rapid ultrasound causes a necessary interruption in workflow; this interruption has been studied more recently to determine methods of expediting saving and transferring information. It needs to be reiterated that the POCUS images are considered legal documents¹that should become part of the patient’s medical record. This protocol may vary depending on local or institutional procedures. Even in those countries that do not have elaborate medical records systems, at the very least, a copy of a written summary should be documented in the patient’s paper record. It is also helpful to have a logbook of all the scans done in a particular patient unit, such as an obstetrical ward.

Most large institutions provide digital recording and archiving into their data systems and electronic medical records. But even with this technology, there are deficits. Nomura et al² published a study demonstrating the types of information in POCUS reports that were deficient among emergency department (ED) physicians, who have access to such systems. This challenge seems universal; Aziz et al³ published a British study of ED physicians who had similar challenges. The most common discrepancies noted in documentation were identified, and mitigation strategies were proposed.

“…accurate documentation of POCUS is essential, especially in cases where POCUS has been used to change management, facilitate decision making or been used to compare clinical status across time. Poor documentation affects the quality and safety of patient care as verbal handovers can be misconstrued or the information not given which also has medicolegal implications…” (Aziz et al, pg 2)³

The following is a review of the documentation guidelines recommended by some sonographic societies.

Essential Documentation

The AIUM (American Institute of Ultrasound in Medicine)⁴ provided an overview of documentation in 2014 that included the following minimum recommendations:

1. Essential Components:

Patient name and other identifying information
Facility’s identifying information
Date of ultrasound exam
Annotation: image orientation (long, sagittal, transverse)

Additional AIUM guidelines:

Permanent record of exam and interpretation

Images (normal and abnormal) to be recorded in retrievable format

Images should be retained consistent with clinical needs and relevant legal or facility requirements

Communication between the ultrasound provider and any healthcare provider should be clear, timely, and in a manner that minimizes potential errors.

Maintenance of patient confidentiality

Essential Components

Although these relate to standard ultrasound exams, all are still relevant, even to a less-detailed point-of-care ultrasound

SDMS Documentation Standard

The SDMS (Society of Diagnostic Medical Sonography) (5) has published a list of components for ultrasound documentation, with the recommendation that continuity of care, accuracy of care, and quality assurance are all strong considerations. Documentation must be in accordance with collaborating physicians, facility policies and other protocols within the practitioner’s setting.

1.6.1 Provides timely, accurate, concise, and complete images and documentation to the interpreting physician.

1.6.2 Documents adaptations of the facility’s protocol including, but not limited to, any contraindications, insufficient patient preparation or inability or unwillingness to complete the examination or procedure, or any physical circumstances under which the examination or procedure was performed.

1.6.3 Provides a written or electronic sonographer’s report of the examination or procedure images, findings, or results to the interpreting physician, and if needed (e.g., due to critical examination or procedure images, findings, results, or the patient’s condition), a verbal report.

Essential Components

Although these relate to standard ultrasound exams, all are still relevant even to a less-detailed point-of-care ultrasound

Table 1 is a worksheet that condenses the essentials for point-of-care ultrasound.^4,5

Table 1. Combined AIUM and SDMS Guidelines

AIUM	SDMS
Patient name and ID number	same
Date and time	same
Provider	same
Facility or location of exam	same
Performing provider	same
Relevant clinical information	Patient’s condition
Type of exam performed (ob etc)	same
Type of ultrasound (TAUS, TVUS)	same
	Exam report: Images Findings Results
For QA: -appropriate anatomic and sonographic terminology -anatomic location and laterality -image orientation when appropriate	Accurate measurements – avoid using descriptors like “large’ or “small”
-Image indication -output display documented or indicated on image	Exam limitations (body habitus, pt refusal, etc)
	DOCUMENTATION OF WRITTEN COMMUNICATION OR VERBAL COMMUNICATION ABOUT CRITICAL FINDINGS

In summary, the essentials for documentation for a POCUS exam are:

Patient name and identifying information
Date of ultrasound exam
Relevant clinical information
Specific ultrasound exam indicated or intended
Name of provider requesting and performing exam
Type of transducer used (transabdominal, transvaginal)
Use of appropriate sonographic terminology
Size descriptions should include specific measurements (not “large” or “small”)

Documentation Templates

Figure 2 shows an example of one type of POCUS ultrasound report. POCUS templates can be developed or modified to fit your practice setting. Other sample reporting templates will be provided in subsequent courses. Some electronic records systems allow providers to create their own templates; others may have pre-developed templates specific to the type of exam.

Figure 1. Documentation templates - sample for pregnancy dating and viability.

Standard Ultrasound Report from Radiology

This is a sample of a report from a radiologist on a patient being scanned for a biophysical profile. In the subsequent course on 2^nd and 3^rd Trimester Obstetrics, the amniotic fluid index was 31 cm, which indicates an abnormality known as polyhydramnios. Although this radiologist verified the fluid level, he or she did not indicate that the referring provider was advised of this abnormality.

Figure 2. Standard ultrasound report.

Annotation on the Image

In addition to a written report describing the ultrasound, each image needs to be correctly annotated. It should never be assumed that the person viewing your image will readily know the structure you are viewing or its orientation. This is something we described briefly in a previous section, but the following slides will give examples of why we need to do this.

Figure 3. Example 1 of incomplete annotation.

In this image we see a round, hypoechoic structure. We do not have any annotation on it, however to let us know what it represents or where in the body it is located. It could represent a cyst in the neck, an ovarian cyst, or even an empty gestational sac. We also do not know if this view is long (sagittal) or transverse. These are all critical differences! This image has no interpretive value without annotation.

Let’s say a cyst is annotated as a right ovarian cyst, and she returns in 6 weeks for a follow up. At that time, a cyst that looks identical to the previous one is seen; but this time it is noted on her left side. This could mean that an error was made on the previous scan, or the first one resolved and now she has one on the other side. Without full annotation and documentation, it would be difficult to decide

Figure 5 is an example of an obstetric scan. The green dot marker indicates that the baby’s head is pointed either to the mother’s head or her right side. But without any additional information we cannot tell from the image. This additional documentation may not matter if the person scanning understands the orientation he or she is using. However, the next provider that sees this woman needs to be certain of the position of the baby, say, for labor management. If the baby is breech during labor, then a vaginal delivery is possible in some cases. If the baby is in transverse lie, this changes the management, likely necessitating a C/Section. If this image has appropriate annotation on it (orientation to the mother), there is proof of the baby’s real position at the time she was scanned.

Figure 4. Example 2 of incomplete annotation.

Correctly Annotated

The image in Figure 6 was correctly annotated – it is easy to see where the structures are since they are labeled. Long or Sagittal was not annotated; however, this view of the uterus can only be obtained in a sagittal plane, so the sonographer did not deem it necessary to write it out.

Figure 5. Correctly annotated image of a uterus.

Critical Findings

When a point-of-care ultrasound is done and an abnormality that could have serious or urgent implications (such as a suspected ectopic pregnancy) is suspected, it is ESSENTIAL to have a mechanism to refer that woman to a more senior provider or physician.

This means also that in your study of ultrasound it is critical that you become so familiar with what is normal, an abnormality will be clearly identified when seen. This course does not instruct on specific diagnostic criteria but instead provides the learner with the skill to identify abnormalities and consult or refer.

When referring or consulting for an urgent clinical situation, it is essential that you document the conversation (including date and time) with that provider, as well as the recommended follow up as instructed to the patient. This allows you to demonstrate that the woman’s condition and management were fully explained and documented.

The next slide is an example of a critical finding report with these essentials

AIUM: If the interpreting provider believes that any delay in the results of the ultrasound examination would have an adverse effect on the patient’s outcome, communication should occur directly between the interpreting provider and the patient’s health care provider. Communication may be verbal or electronic

A publication in November 2024 in New Zealand¹² highlighted medical errors of ultrasound report omissions or failure to communicate abnormal findings which led to fetal deaths. The types of omissions included failure to report absent fetal kidneys and bladder, airway malformation, and abnormal biophysical profile.

Critical Findings Report

This is an example of a radiologist’s report and documentation of a critical finding. This radiologist completed all the essential elements for a critical exam, including an image of the suspicious area, and her overall impression. In THIS report she noted that she discussed the findings with the provider, along with the date and time.

Figure 6. Example of critical findings report with follow up indicated.

This report was generated by the ultrasound machine. The information was derived from what was input into the computer before and during the exam:

Patient information
Provider information
Date and time of scan
Place of exam
The indication for the exam (BPP)
Measurements taken
Other descriptions and annotations by the sonographer
Biophysical profile information recorded during the scan
Comments at the end were entered by the sonographer, writing out his/her impressions

Figure 7. Ultrasound machine generated report.

Annotation and documentation will continue to be reiterated through the remainder of the courses to follow.

SUMMARY – Documentation and Reporting

To summarize, documenting and reporting are critical components of the care provided by a practitioner in performing a point-of-care ultrasound. In addition to the written report, however, the ultrasound report must be substantiated with at least one image.

Essential components of the documentation include:
Patient name and other identifying information
Facility’s identifying information
Date of ultrasound exam and name of provider performing exam
Clinical indication
Correct annotation: orientation, structures labeled
Images
Consultation/communication with other providers for critical findings
Clinical assessment and follow up

Foundations of Women's Point-of-Care Ultrasound

Chapter 9 Documentation and Reporting