Documentation, preliminary findings and sonographer's technical impression

Accurate documentation of each ultrasound examination is a medico-legal requirement.  The American Institute of Ultrasound in Medicine (AIUM) Practice Parameter for Documentation of an Ultrasound Examination states the following:

"Requirements for the Ultrasound Examination

Ultrasound examinations should be recorded in a manner that will allow subsequent review for adequacy for diagnostic purposes. Although for some applications still-frame images may suffice, archiving of dynamic imaging (video/cine loop) may be required or preferred for some types of examinations (see relevant practice parameters).

Whether still-frame images or cine images (or both) are captured, the archived images should contain the following:

• Patient's name and other identifying information

• Facility's identifying information

• Date and time of the ultrasound examination

• Output display standard (thermal index and mechanical index)

• Label of the anatomic location and laterality, when appropriate

• Image orientation when appropriate

For digitally stored static or dynamic images, the information should be contained in the metadata and readable/displayable during review of the images. For analog records, identifiers should be contained on the image.

If a worksheet is used and retained, documentation on the worksheet should contain, at a minimum, the patient's name and other identifying information, date and time of the ultrasound examination, and name of the person(s) who performed the examination and completed the worksheet."

While the above AIUM Practice Parameter does not provide further detail regarding the worksheet/technical impression, we know that the practice of diagnostic medical sonography is highly operator-dependent.  It is also the only diagnostic imaging modality in which the technologist routinely provides a technical impression and/or worksheet for each case and this document is incorporated into the medico-legal report.  For this reason, the sonographer must be able to use accurate sonographic and medical terminology to clearly provide an accurate and timely technical impression and/or worksheet.

The current SDMS Scope of Practice states the following: