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Diagnostic Radiologist
20-25 minutes

Normal Abdominal Ultrasound Template

The Ultrasound Abdomen (Normal) template by s10.ai is expertly crafted for sonologists, sonographers, and radiologists to accurately document normal abdominal ultrasound findings. This comprehensive template includes sections for patient information, clinical indications, technical details, and detailed observations of the pancreas, liver, gallbladder, kidneys, and spleen. By ensuring standardized and thorough reporting, this template is an indispensable resource for radiologists aiming to enhance the precision and efficiency of their normal ultrasound abdomen reports. Adopt this template to optimize your documentation workflow and ensure the highest accuracy in your ultrasound reporting.

3,050 uses
4.5/5.0
D
Dr. Emily Thompson
Template Structure

Organized sections for comprehensive clinical documentation

Abdominal Ultrasound
Patient Information:
Name: [Mention patient's name] (mention only if available)
Age & Gender: [Mention patient's age and gender] (mention only if available)
Date of Birth: [Mention patient's date of birth] (mention only if available)
Medical Record Number: [Mention patient's medical record number] (mention only if available)
Clinical Indication:
[Describe clinical indication] (describe the reason for the ultrasound examination, including any symptoms or medical history relevant to the scan)
Technical Information:
Date of Examination: [Date] (include the date the ultrasound was performed)
Sonographer: [Sonographer Name] (include the name of the sonographer or technician who performed the scan)
Equipment Used: [mention details of equipment and transducer used] (e.g., GE Logiq, curvilinear transducer operating at 2-5MHz)
Type of Examination: Abdominal Ultrasound
Findings:
The pancreas is well visualized and has a normal size, shape, and echotexture, with no duct dilation.
The liver is of normal size, shape, and echotexture with no intrahepatic duct dilation or focal lesion seen. The portal vein measures [mention size of portal vein in mm] mm with normal flow.
The gallbladder is normal with a wall thickness of [mention thickness of gallbladder wall in mm] mm. No gallstones, polyps, or sludge are seen within the lumen and the patient is sonographic Murphy’s negative. The CBD measures [mention size of common bile duct in mm] mm.
Both kidneys are of normal size and shape with smooth contour and normal cortical echotexture. The central echogenic complexes have a normal appearance with no hydronephrosis. The right kidney measures [mention length and width of right kidney in cms (for e.g. 8 x 4)] cm and the left kidney measures [mention length and width of right kidney in cms (for e.g. 8 x 4)] cm.
The spleen is of normal size, shape, and echotexture with a diameter of [mention size of spleen in cm] cm.
Impression:
[list each impression or diagnosis with brief description] (use "No significant abnormality is seen in present examination" if impression is normal)
(Never come up with your own patient details, assessment, plan, interventions, evaluation, and plan for continuing care - use only the transcript, contextual notes, or clinical note as a reference for the information included in your note. If any information related to a placeholder has not been explicitly mentioned in the transcript, contextual notes, or clinical note, you must not state the information has not been explicitly mentioned in your output, just leave the relevant placeholder or section blank. Use as many bullet points as needed to capture all the relevant information from the transcript.)
Sample Clinical Note

Example of completed documentation using this template

Ultrasound Abdomen
Patient Information:
Name: John Doe
Age & Gender: 45, Male
Date of Birth: 01/01/1978
Medical Record Number: 123456
Clinical Indication:
Patient reports upper abdominal pain and has a history of mild jaundice. The ultrasound is conducted to assess the liver, gallbladder, pancreas, and kidneys for any irregularities.
Technical Information:
Date of Examination: 10/10/2023
Sonographer: Jane Smith
Equipment Used: GE Logiq, curvilinear transducer operating at 2-5MHz
Type of Examination: Ultrasound Abdomen
Findings:
The pancreas is clearly visualized and exhibits normal size, shape, and echotexture, with no duct dilation observed.
The liver appears normal in size, shape, and echotexture, with no intrahepatic duct dilation or focal lesions detected. The portal vein measures 12 mm with normal flow.
The gallbladder is normal with a wall thickness of 3 mm. No gallstones, polyps, or sludge are present within the lumen, and the patient is sonographic Murphy’s negative. The CBD measures 5 mm.
Both kidneys are normal in size and shape with smooth contours and normal cortical echotexture. The central echogenic complexes appear normal with no hydronephrosis. The right kidney measures 10 x 5 cm and the left kidney measures 10 x 5 cm.
The spleen is normal in size, shape, and echotexture with a diameter of 11 cm.
Impression:
- No significant abnormalities are observed in the current examination.
Clinical Benefits

Key advantages of using this template in clinical practice

  • The "Ultrasound Abdomen" clinical template is an essential tool for healthcare professionals seeking to streamline the documentation of abdominal ultrasound examinations. This comprehensive template includes sections for patient information, clinical indication, technical details, and detailed findings, ensuring a thorough and accurate record of the ultrasound procedure. With high-search healthcare keywords integrated, this template enhances clinical efficiency and accuracy, making it easier for clinicians to document normal and abnormal findings, such as the size and echotexture of the pancreas, liver, gallbladder, kidneys, and spleen. By adopting this template, clinicians can improve diagnostic precision and patient care outcomes, while also facilitating seamless communication within the healthcare team. Explore the benefits of implementing this template to enhance your clinical documentation process today.
Frequently Asked Questions

Common questions about this template and its usage

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