Point-of-Care Ultrasound (POCUS) Report

Date/Time: [exam date and time]

Patient: [name, MRN, DOB]

Performing Clinician: [name and credentials]

Interpreting Clinician: [name and credentials] (Include if different from performing clinician)

Indication

[Clinical indication and specific clinical question(s)] (State in one to three concise sentences)

Exam Performed

Scope: [focused / limited]

• Cardiac: [views obtained with adequacy: PLAX, PSAX, A4C, Subcostal, IVC as applicable] (Note reason if any view Limited or Not obtained)
• Lung: [zones examined with adequacy] (Specify zone approach and laterality)
• eFAST: [views obtained with adequacy: RUQ, LUQ, Suprapubic, Subxiphoid, Anterior lungs as applicable]
• DVT: [vessels examined with adequacy: CFV, SFJ, FV, Popliteal, Trifurcation as applicable] (Note if Doppler used)
• Biliary: [views obtained with adequacy: GB long/short axis, CBD as applicable]
• Other: [specify application and views obtained]

(Include only applications performed; omit others entirely)

Findings

(Organize by application. Use Present / Absent / Indeterminate with reason if indeterminate. Include measurements when clinically relevant.)

• Cardiac: [pericardial effusion, tamponade physiology, LV function, RV size/function, IVC diameter and collapsibility, gross valvular abnormalities]
• Lung: [pleural sliding by side, B-lines pattern and distribution, consolidation, pleural effusion by side, lung point if applicable]
• eFAST: [RUQ free fluid, LUQ free fluid, suprapubic free fluid, pericardial effusion, pneumothorax assessment by side]
• DVT: [compressibility at each vessel examined, Doppler findings if obtained]
• Biliary: [gallstones, sonographic Murphy sign, GB wall thickness, pericholecystic fluid, CBD diameter, intrahepatic ductal dilation]
• Other: [relevant findings for specified application]

(Include only applications performed; omit others entirely)

Interpretation

Overall Impression: [concise summary addressing the clinical question(s)]

Per-Application Interpretation: [interpretation tied to findings for each application performed, prioritizing urgent findings] (Include only applications performed)

Limitations: [significant limitations impacting interpretation] (Include only if applicable)

Recommendations: [follow-up imaging, consultation, or repeat study if clinically indicated] (Include only if indicated)

[Critical findings communication: what communicated, to whom, when] (Include only if critical or actionable findings were communicated)

[Images archived in [system name]] (Include only if required by facility policy)