Musculoskeletal Ultrasound Interpretation Report

Patient: [patient name / MRN / DOB]

Exam Date/Time: [date and time of acquisition]

Exam: [exam name, e.g., "US MSK—Shoulder"]

Body Region/Laterality: [specific region and side, e.g., "Right wrist"]

Exam Scope: [Complete / Limited] (If limited, specify targeted structure(s).)

Ordering Clinician: [name and service]

Interpreting Clinician: [name and credentials]

Indication

[Primary clinical question, symptomatic area with laterality, duration/onset, and relevant context such as prior surgery, injections, or known inflammatory disease] (State the clinical question addressed if requisition is vague. Keep to 1–3 sentences.)

Comparison

[Prior relevant imaging with type, body part, date, and whether images/report were reviewed] (If none, state "None available.")

Technique

Transducer: [type and frequency]
Scan Method: [orthogonal planes; dynamic assessment performed / not performed]
Doppler: [Color Doppler performed / Power Doppler performed / Not performed]
Structures Evaluated: [list of structures assessed]
Limitations: [None / describe limitations affecting evaluation]

Findings

Region examined: [confirmation of anatomic region and laterality]

[Findings organized by relevant anatomic structures—tendons, sheaths, ligaments, bursae, joint/synovium, bone cortex, nerves, soft tissues—as applicable to the exam. For each abnormality, describe location, size, severity, and Doppler signal when assessed.] (For inflammatory assessments, document effusion, synovial hypertrophy, and Doppler hyperemia as separate observations. If erosion is suspected, state whether cortical break was confirmed in two perpendicular planes. Include only structure categories that were evaluated. Conclude with pertinent negatives relevant to the clinical question.)

Impression

1. [Primary conclusion answering the clinical question, with laterality and severity]
2. [Secondary finding or differential consideration, if applicable]
3. [Additional relevant finding(s), if applicable]

(Provide 1–5 items ordered by clinical priority. Use calibrated language such as "consistent with," "most compatible with," or "cannot exclude" as appropriate.)

Recommendations

[Actionable guidance: clinical correlation, follow-up imaging, procedural considerations, or specialist referral] (Include only when actionable. Omit this section entirely if findings are normal and no further action is warranted.)