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Gynecologist
30-45 minutes

Sonography

This ultrasound documentation template is perfect for Radiologists seeking to meticulously document pelvic ultrasound findings. It features sections for referring physician information, patient medical history, imaging techniques, findings, and clinical impressions. Optimized for use with s10.ai, this template guarantees precise and efficient recording of ultrasound results. Radiologists can leverage this template to enhance their workflow efficiency and maintain thorough patient records, encouraging seamless adoption and implementation in clinical practice.

4,346 uses
4.8/5.0
D
Dr. Samuel Carter
Template Structure

Organized sections for comprehensive clinical documentation

REFERRING PHYSICIAN: [referring physician]
HISTORY: [patient's history or reason for the ultrasound]
TECHNIQUE: Real-time ultrasound imaging was conducted using a multi-frequency curvilinear transducer with color/energy and PW Doppler on a Philips Affinity 70G.
FINDINGS: [details of the ultrasound findings]
IMPRESSION: [conclusion or impression based on the findings]
Dictated by: [name of the dictating physician]
Technician: [name of the technician]
Sample Clinical Note

Example of completed documentation using this template

REFERRING PHYSICIAN: Dr. Emily Carter
HISTORY: The patient is a 32-year-old female experiencing pelvic pain and irregular menstrual cycles. An ultrasound was ordered to assess for potential ovarian cysts or other issues.
TECHNIQUE: Real-time ultrasound imaging was conducted using a multi-frequency curvilinear transducer with color/energy and PW Doppler on a Philips Affinity 70G.
FINDINGS: The ultrasound identified a 4 cm simple cyst on the right ovary, with no signs of solid components or septations. The left ovary appeared normal, and there was no free fluid in the pelvic area.
IMPRESSION: The results are indicative of a simple ovarian cyst on the right ovary. A follow-up ultrasound in 6-8 weeks is advised to confirm resolution.
Dictated by: Dr. Sarah Johnson  
Technician: Lisa Nguyen
Clinical Benefits

Key advantages of using this template in clinical practice

  • Enhance your clinical documentation with our comprehensive ultrasound report template, designed to streamline the process for healthcare professionals. This template includes essential sections such as REFERRING PHYSICIAN, HISTORY, TECHNIQUE, FINDINGS, and IMPRESSION, ensuring a thorough and accurate record of each ultrasound examination. Utilizing high-performance equipment like the Philips Affinity 70G, this template supports real-time imaging with advanced features such as multi-frequency curvilinear transducers and color/energy and PW Doppler. Clinicians can efficiently document and communicate critical diagnostic information, improving patient care and facilitating seamless collaboration among medical teams. Explore and implement this template to enhance your practice's efficiency and diagnostic accuracy today.
Frequently Asked Questions

Common questions about this template and its usage

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