FAST/eFAST Ultrasound Procedure Note

FAST/eFAST Ultrasound Procedure Note

Patient: [name, MRN]
Date/Time: [date and time performed]
Location: [ED / trauma bay / ICU / other]
Study Type: [FAST / eFAST] – limited/focused bedside ultrasound
Performed/Interpreted by: [clinician name and credentials] (If performed and interpreted by different individuals, specify Operator and Interpreter separately.)

Indication

[Clinical context: trauma mechanism, hemodynamic status] – [Clinical question: evaluate for intraperitoneal free fluid, pericardial effusion, pneumothorax, pleural fluid] (One to two concise sentences.)

Views and Findings

(Document each view on a single line. Use Adequate, Limited, or Not obtained for adequacy. Use Present, Absent, or Indeterminate for findings. If Limited or Not obtained, include the reason in parentheses, e.g., body habitus, subcutaneous emphysema, bowel gas, patient positioning, wounds/dressings, ongoing resuscitation.)

Cardiac (subxiphoid): [Adequate / Limited / Not obtained] – Pericardial effusion: [Absent / Present / Indeterminate] [; size/description if present]

RUQ (hepatorenal): [Adequate / Limited / Not obtained] – Free fluid: [Absent / Present / Indeterminate] [; location if present]

LUQ (splenorenal): [Adequate / Limited / Not obtained] – Free fluid: [Absent / Present / Indeterminate] [; location if present]

Pelvic: [Adequate / Limited / Not obtained] – Free fluid: [Absent / Present / Indeterminate] [; location if present]

(Include the following thoracic views only if Study Type = eFAST.)

Right Thoracic: [Adequate / Limited / Not obtained] – Lung sliding: [Present / Absent]; Pneumothorax: [No evidence / Findings consistent with / Indeterminate]; Pleural fluid: [Absent / Present / Indeterminate]

Left Thoracic: [Adequate / Limited / Not obtained] – Lung sliding: [Present / Absent]; Pneumothorax: [No evidence / Findings consistent with / Indeterminate]; Pleural fluid: [Absent / Present / Indeterminate]

Impression

FAST/eFAST Result: [Positive / Negative / Indeterminate]

[Summary of key findings in clinical priority order: pericardial findings, then pneumothorax, then pleural fluid, then intraperitoneal free fluid] (For negative exams, state "No free fluid identified in examined windows" rather than implying exclusion of injury. Note any significant limitations affecting interpretation.)

Images: [Archived per institutional protocol / Unable to archive – reason]
Communication: [For positive or indeterminate findings: person notified, time, method / Results discussed at bedside with treating team]
Complications: [None / description if applicable]