How Important are Ultrasound Reports in Veterinary Ultrasound?

Greetings Scan Squad! 

Does your clinic have a standard reporting system for ultrasounds? 

A written report, that documents your findings, as well as your interpretation of those findings, is essential. This should be included within your patient’s record. To increase your standard of care, this report should be consistent between the veterinarians in your clinic. It should contain several components:

1.    Each organ should be assessed and described based upon organ size, shape, echogenicity and whether it appears normal or abnormal. A description of all abnormal findings (once again, using size, shape and echogenicity) and their locations should be included. 

2.    Make a note of anything that may have impacted your scan! Have you ever considered documenting factors that may have affected your ability to obtain good image clarity? Did the patient have a large volume ascites or significant peritonitis with fluid or inflammation obscuring your image? Did you look for the medial iliac lymph nodes but couldn’t find them? Chances are, if you can’t find them, they’re normal and you should make a note that you looked and they weren’t seen! Was it a deep-chested dog, making the liver difficult to assess? Were you not able to sedate the patient due to medical concerns? 

3.    A summary of your findings, complete with your interpretation, differentials and recommendations. 

4.    A description of any ultrasound-guided procedures that were performed. Did you collect a cystocentesis, FNA thoraco/abdominocentesis? 

Don’t forget to save labelled images of each organ system, even if they appear normal! Our ultrasound guide helps identify which images to collect. 

You can always create your own template. However, I remember what it was like to be a time-poor clinician, so I thought I would create a template for you, so you can go ahead and take that toilet break, finish your cold coffee or have your 4pm 'lunch break’! Find our completed template HERE. Even better if you can nab it whilst it’s still on sale! 

Each Report Template includes a ‘fill-in-the-blank’ ultrasound template and two example ultrasound reports. The completed reports are two of my own actual reports and include the descriptive report, interpretation of the findings and corresponding images. 

The above image is a sample of the ultrasound report template - ready to go, saving you tons of time!