How should a sonographer document the findings of an ultrasound examination?

Documenting the findings of an ultrasound examination through detailed written reports is essential for maintaining clarity, accuracy, and comprehensive patient records. A well-constructed report provides critical information for healthcare providers, including the interpretation of ultrasound findings, measurements, and any pertinent clinical correlations. Including images and annotations enriches the report, enabling other medical professionals to visualize the observations made during the examination.

Written documentation serves multiple purposes: it supports continuity of care, allows for legal accountability, and provides a reference for future examinations or interventions. Such detailed reporting is also crucial for communicating findings effectively among the healthcare team and ensuring that the information is accessible for future clinical decision-making.

While other methods like verbal summaries, checklists, or audio recordings may have their place in certain contexts, they often lack the thoroughness and permanence that written reports provide. A written report that includes images and annotations offers a comprehensive approach that enhances the utility and reliability of the ultrasound examination findings.