The first and most essential piece of your documentation needs to be the captured (and properly annotated) image itself. You will want either a saved or a printed image from every ultrasound exam or procedure you perform.

If it’s a printed image, you will keep this in the patient’s file, usually taped to a sheet of paper with “Ultrasound Image” printed at the top (or taped to the actual report). If it is a digital image, you can attach this to the patient’s record in your EMR system, or you can simply save all of your images in a folder named “Ultrasound Images” on one of your computers. (Just be sure to back up your files every week, or at least once a month.)

The important components you want every image to contain include the following:

  • A reasonably clear image — ideally two images, one transverse and one longitudinal.
  • The patient’s name and an associated ID number.
  • Your name or the name of the practice.
  • The time and date the exam was performed.
  • A title (including “Left” or “Right,” whatever it is you are looking at, and “INJ” or “Injection” if it’s a guided injection).
  • At least one element of the anatomy labeled (so we have some kind of landmark to orient ourselves).
  • Any location of an injection (normally marked with an arrow as well as the letters “INJ”).
  • Any pathology (normally marked with an arrow and labeled).

 

annotated