Transesophageal Echocardiogram Report

Date/Time: [study date and time]

Patient: [name, MRN, DOB, age, sex]

Facility: [facility/site]

Ordering Clinician: [name, role/service]

Performing Personnel: [proceduralist/sonographer/anesthesia/nursing as applicable]

Interpreting Physician: [name, credentials]

Indication

[Primary indication and clinical question] (1–3 lines. Include pertinent clinical context such as rhythm, prosthetic valves, or suspected diagnosis. Note comparison studies if available: type, date, and whether images/report were reviewed. If indication not provided, state: "Indication: not provided on requisition.")

Procedure

Type/Scope: [Comprehensive / Targeted] (If targeted, specify focused structure(s) or question.)

Components: [2D / Color Doppler / Spectral Doppler / 3D / Contrast] (List modalities used.)

Sedation: [None / Moderate sedation / Anesthesia / See anesthesia record] (Include medications with doses/routes when documented.)

Technique: [Probe insertion ease/difficulty, patient tolerance, image quality: good / fair / poor, specific limitations, structures not assessed]

Complications: [None / describe event and management]

Findings

(Document concise findings tied to indication. Use "not assessed" for structures intentionally omitted; "not visualized" or "technically limited" for inadequate imaging; "cannot exclude" for clinically important uncertainty. Do not infer normalcy from limited visualization.)

Ventricles

• [LV size and systolic function] (Include EF estimate and method; regional wall motion if assessed.)
• [LV thrombus or mass] (Present / absent; note visualization adequacy.)
• [RV size and systolic function]

Atria and LAA

• [LA size]
• [LAA visualization] [well visualized / technically limited / not visualized]
• [LAA thrombus] [present / absent / cannot exclude]
• [Spontaneous echo contrast] [present / absent] (Grade if applicable.)
• [LAA emptying velocity] (Include value when obtained.)
• [RA size and other atrial findings] (Only if relevant.)

Interatrial Septum

• [Septal morphology] [intact / aneurysmal / defect present]
• [Shunt assessment] (Method, rest/provocation, result with direction and magnitude.)

Valves

• [Aortic valve] (Morphology, stenosis/regurgitation severity, mechanism.)
• [Mitral valve] (Morphology, stenosis/regurgitation severity, mechanism.)
• [Tricuspid valve] (Morphology, regurgitation severity.)
• [Pulmonic valve] (Only if assessed.)
• [Prosthetic valves] (Type, position, function, gradients, regurgitation/paravalvular leak.)

Aorta

• [Dimensions] (Root, ascending, arch, descending as relevant.)
• [Atheroma] (Thickness, mobility, grade if used.)
• [Dissection or other pathology] (Presence/absence, extent.)

Pericardium and Other

• [Pericardial effusion] (Size, distribution, tamponade physiology if present.)
• [Intracardiac devices/leads] (Position and findings.)
• [Extracardiac findings] (Only if clinically pertinent.)

Summary

• [Key positive findings with severity and anatomic specificity]
• [Pertinent negatives tied to indication]
• [Adequacy statements] (e.g., "LAA well visualized, no thrombus" vs "thrombus cannot be excluded due to limited views.")
• [Cardioversion/procedure clearance statement if applicable] [supports proceeding / does not support proceeding] (Include rationale.)
• [Critical findings communication] (What communicated, to whom, when, method.) (Only if critical or urgent findings present.)

Interpreting Physician Signature: [name, credentials]

Date/Time of Final Report: [date and time]