ID: 201638
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Fordigitallystoredstaticordynamicimages,theinformationshouldbecontainedinthemetadataandreadable/displayableduringreviewoftheimages.Foranalogrecords,identiersshouldbecontainedontheIfaworksheetisusedandretained,documenta-tionontheworksheetshouldcontain,ataminimum,thepatientsnameandotheridentifyinginformation,dateandtimeoftheultrasoundexamination,andnameoftheperson(s)whoperformedtheexamina-tionandcompletedtheworksheet.FinalReportProvidedbytheInterpretingProviderAsignednalreportoftheultrasoundndingsandimpressionshouldbeincludedinthepatientsmedi-calrecordandisthedenitivedocumentationofthestudy.Thenalreportshouldincludebutisnotlim-itedtothefollowingdemographiccomponents:snameandotheridentifyinginformationNameoftheorderingproviderLocationoftheultrasoundfacilityandcontactRelevantclinicalinformation,includingtheindica-tionfortheexaminationand/orcurrentversionoftheappropriateInternationalClassicationofDis-DateandtimeoftheultrasoundexaminationcultrasoundexaminationperformedIfendocavitarytechniquesareused,themethodshouldbespeciThebodyofthereportshouldincludeadescrip-tionoftheexamination,includingthefollowingAdescriptionofthestudiesand/orproceduresCommentsonthecomponentsoftheexaminationasoutlinedintherelevantpracticeparameter(s)Adescriptionofanycontrastmediaand/orphar-maceuticalsused(includingrouteofadministrationanddose,whenapplicable)Additionalmedications,catheters,ordevicesusedshouldbeindicatedAnysignicantpatientreactionorcomplicationshouldbedocumentedAnatomicmeasurements(eg,fetalbiometry),asappropriate,andmeasurementofabnormalstruc-turesororgans,iftakenAdescriptionofexaminationndings,usingappro-priateanatomicandultrasoundterminology(useofacronymsandabbreviationsshouldbeavoided)Theconcludingstatementsorsummaryofthereportshouldincludethesecomponents:Animpression,conclusion,orsummarystatementAspecicdiagnosisordifferentialdiagnosis,ifappropriateArecommendationforfollow-upstudies,ifclini-callyapplicableAnaccountingofanyfailuretoincludestandardviewsorothernecessarycomponents(aslistedintheappropriatepracticeparameter)Ifpriorrelevantimagingstudieswerereviewed,astatementofcomparisonshouldbeincludedDetailsconcerninganyprovider-to-providercom-municationincasesinwhichadelayincommuni-cationmayhaveanadverseeffectonthepatientTheinterpretingproviderhastheresponsibilitytomakethereportavailabletotheorderingprovider,andtheorderingproviderhasaresponsibilitytoreviewthenalreport.Theimagingfacilityshouldarchivearetrievablecopyofthenalreportaspartofthepatientsmedicalrecordandensurethattherequestingproviderhasaccesstothenalreportoracopyofthereport.Archivingmethodsandcommuni-cationofreportsandimagesmustcomplywithlocal,state,andfederalregulations.ReportingofNonroutineResultsIncertaincircumstances,suchascasesinwhichimmediatepatienttreatmentisnecessaryorinkeep-ingwithexpectationsofaparticularpracticeenviron-ment,apreliminaryreportoftheultrasoundresultsmaybeprovidedtothepatientsreferringhealthcareprovider(s)beforegenerationofthenalreport.Thisincludespracticeenvironmentsandsituationsinwhichthereferring,performing,andinterpretingAIUMPracticeParameterforDocumentationofanUltrasoundExaminationJUltrasoundMed2020;39:E1 providerarethesameperson,suchasinpoint-of-careultrasoundinwhichapreliminaryimpressionisdocu-mentedduringthecourseofcare.Thepreliminaryreportmustcontainthepatientidentifyinginformation,requestingprovidersinforma-tion,interpretingproviderscontactinformation,pertinentclinicalinformation,dateandtimeoftheultra-soundexamination,andspecicultrasoundexaminationperformed.Thepreliminaryreportcontainslimitedinformationandmaynotcontainalloftheresultsthatwillsubsequentlybefoundinthenalreport.Preliminaryreportsshouldbelabeledassuchandshouldbearchived,sinceclinicaldecisionsmayhavebeenmadeonthebasisofapreliminaryreport.Anycantdiscrepancybetweenthepreliminaryreportandnalreportshouldbecommunicatedtothepatientsprovideranddocumentedinthereport,includingthedate,time,andmethodofcom-municationofthediscrepancyandnalimpression.Iftheinterpretingproviderbelievesthatanydelayintheresultsoftheultrasoundexaminationwouldhaveanadverseeffectonthepatientsout-come,communicationshouldoccurdirectlybetweentheinterpretingproviderandthepatientshealthcareprovider.Communicationmaybeverbalorelec-tronic,providedthemeansofconveyancecomplieswithallapplicablefederal,state,andlocalprivacylawsandprovidesacknowledgmentthatthecommu-nicationwasreceived.Communicationshouldoccurinatimelymannerinaccordancewiththepatientclinicalconditionandtheultrasoundndings,typi-callyassoonasfeasibleafterinterpretationoftheexamination.Thefacilitysprotocolshouldbefollowedtomini-mizepotentialcommunicationerrors.ThenaloraddendedreportshouldincludealloftheelementsnotedinsectionIII,aswellasthedate,time,andmethodusedtodirectlycommunicatethendingstothepatientshealthcareproviderifsignicantcommuni-cationoccurredbeforethetransmittalofthenalreport.DocumentationandReportingofUltrasound-GuidedProceduresDocumentationoftheinformedconsentcommunica-tionbetweentheproviderandthepatientconcerningtheprocedure(includingrisks,benets,andalternatives)shouldbepartofthemedicalrecordandperformedincompliancewithlocalstandardsandanyapplicablestateandfederallaw.TheJointCommission(TJC)Univer-salProtocolforthePreventionofWrongSite,WrongProcedure,andWrongPersonSurgerymustbefollowed.(http://www.jointcommission.org/standards_information/up.aspx)Recordedimagesappropriatetotheprocedureper-formedshouldbearchivedinaretrievableformattoallowforsubsequentreviewasspeciedinsectionIIabove.Asignednalreportoftheultrasound-guidedpro-cedureshouldbeincludedinthepatientsmedicalrecordandisthedenitivedocumentationoftheproce-dure.Thenalreportshouldbegenerated,signed,anddatedbytheperformingprovider/interpretingphysicianinaccordancewithstateandfederalrequirements.Finalreportsshouldbeavailablewithin24hoursofcomple-tionoftheexaminationor,fornonemergencycases,bythenextbusinessday.nalreportmustcontainallcomponentslistedinsectionIII,andthefollowinginformation:IndicationforultrasoundguidanceDocumentationofcompliancewiththeabove-referencedTJCuniversalprotocolCleardocumentationoftheproceduresiteDescriptionofthetargetandrelevantassociatedstructures,bothnormalandabnormal,ifclinicallyDescriptionoftheessentialelementsoftheprocedureNeedle/devicetypeandgaugeNumberofpassesperformedDeviationsfromstandardtechniquesshouldbedescribedandjustiName(s)ofmedication(s)injectedandamount(s)used,ifapplicableSpecimendescription,type,andamountremoved,ifanyComplications(orlackthereof)sresponsetotheprocedureanddispositionRecommendationsforfollow-upimaging,ifclini-callyindicatedPleaserefertotherelevantparameterforthespe-cultrasound-guidedprocedure,asitmaycontainadditionaldocumentationrequirements.AIUMPracticeParameterforDocumentationofanUltrasoundExaminationJUltrasoundMed2020;39:E1 ThisparameterwascreatedandrevisedbytheAmeri-canInstituteofUltrasoundinMedicine(AIUM).AIUMSubcommitteeMembersAnitaJ.Moon-Grady,MD,chairDavidC.Jones,MD,vicechairAlyssaM.Abo,MDPaulBornemann,MDWilliamLindsley,RDMS,RVTAndrejLyshchik,MD,PhDChristopherL.Moore,MD,RDMS,RDCSAIUMClinicalStandardsCommitteeBryannBromley,MD,chairJamesM.Shwayder,MD,JD,vicechairNirviDahiya,MDRobGoodman,MD,MBBChir,MBARachelLiu,MDJeanLeaSpitz,MPH,CAE,RDMSJohnPellerito,MD,immediatepastchairExpertReviewersBrianD.Coley,MDJoshuaA.Copel,MDAndreiRebarber,MDJamesM.Shwayder,MD,JDOriginalcopyright2002;Revised2019,2014,2008,2007;Renamed2015AIUMPracticeParameterforDocumentationofanUltrasoundExaminationJUltrasoundMed2020;39:E1 PRATICEPARAMETERSAIUMPracticeParameterforDocumentationofanUltrasoundccurateandcompletedocumentationandcommunicationbyallmembersofthediagnosticultrasoundhealthcare JUltrasoundMed2020;39:E10278-4297www.aium.org PRATICEPARAMETERS AIUMPracticeParameterforDocumentationofanUltrasoundccurateandcompletedocumentationandcommunicationbyallmembersofthediagnosticultrasoundhealthcareteamareessentialforhigh-qualitypatientcare.Theremustbeapermanentrecordoftheultrasoundexaminationanditsinterpretation.Imagesofallrelevantareasdefinedintheparticularparameter,bothnormalandabnormal,shouldberecordedandstoredinaretrievableformat(electronicpreferred).Retentionoftheultrasoundimagesandreportshouldbeconsistentbothwithclinicalneedsandwithrelevantlegalandlocalhealthcarefacilityrequirements.Communicationbetweentheinterpretingproviderandthereferringprovidershouldbeclear,timely,andinamannerthatminimizespotentialerrors.Incertaincases,thereferring/ordering,performing,andinterpretingphysicianmaybethesameperson;ifso,thisshouldbedocumented.Allcommunicationshouldbeperformedinamannerthatrespectspatientconfidentialityandcomplieswithrelevantregulations.Thereaderisurgedtorefertotheapplicablepracticeparameterforeachtypeofultrasoundexamination,asitmaycontainadditionaldocumen-tationrequirements.Useofultrasoundwithoutgeneratingaseparatereportisnotaddressedinthisdocument.RequirementsfortheUltrasoundExaminationUltrasoundexaminationsshouldberecordedinamannerthatwillallowsubsequentreviewforadequacyfordiagnosticpurposes.Althoughforsomeapplicationsstill-frameimagesmaysufce,archivingofdynamicimaging(video/cineloop)mayberequiredorpreferredforsometypesofexaminations(seerelevantpracticeparameters).Whetherstill-frameimagesorcineimages(orboth)arecap-tured,thearchivedimagesshouldcontainthefollowing:snameandotheridentifyinginformationsidentifyinginformationDateandtimeoftheultrasoundexaminationOutputdisplaystandard(thermalindexandmechanicalindex)Labeloftheanatomiclocationandlaterality,whenappropriateImageorientationwhenappropriatedoi:10.1002/jum.15187 ©2019bytheAmericanInstituteofUltrasoundinMedicineUltrasoundMed2020;39:E10278-4297www.aium.org