Ultrasound Good Practice Guide

NEMUS guidance on reporting of ultrasound scans

We believe that attention to clinical governance issues, is essential. This includes the way we report our scans. To be credible and professional, all scans should be formally logged and reported. This may even be a short report detailing the use of US to aid central line insertion. 

In many sonography departments, there are DICOM worklists and reporting systems in which electronic recording of images and reports are kept. Many hospitals will demand that there is consistency amongst all users of US. However, there are practicality problems in the emergency department that make it very difficult to enter this information prior to the scan being performed - we may not even know the details of a patient until some time has elapsed. Therefore, we advocate the use of focused paper report forms that can be filled out just after the scan. They should include the basic demographic information (if known) needed and the report should be in the format requested by the Royal College of Radiologists:

  • Indications
  • Findings
  • Conclusion

Below are examples of a reporting proforma. It is simple and focused and doesn’t take ages to fill in! 

Example FAST US report

Example Focused Echo report

If your trust requires you to have electronic reports on a radiology reporting system then it can be transcribed from the paper report at a later stage. You may want to make arrangements for this with admin staff. A copy should also be made of the report for your own logbook/portfolio of practice. 

Benefits of doing formal reports include the following: 

logs your departmental US activity (helpful in trying to justify a new machine and possibly for PBR calculations) 
stops meddling as you should only perform a scan that you are capable of performing and prepared to be logged 
your report is available to all interested parties and an official investigation, albeit to only answer a ‘rule-in’ focused question 
it is desirable to establish good relationships with the radiology department and formal reporting sends the right message 
the formal reporting of all scans you do enables personal audit of your practice