Ultrasound Report (Diagnostic)

Patient Name: [Patient full name]

DOB: [Date of birth]

MRN: [Medical record number]

Exam Date/Time: [Date and time of examination]

Exam Type: [Anatomic region and protocol]

Ordering Clinician: [Name and credentials]

Interpreting Clinician: [Name and credentials]

Report Status: [Preliminary / Final]

Indication

[Clinical question to be answered and pertinent history affecting interpretation] (Phrase as the question to be answered. Include key history that materially affects interpretation such as prior surgeries, known malignancy, pregnancy status, or relevant symptoms. If no indication is provided, state exactly: "Indication: Not provided.")

Comparison: [Prior studies reviewed with modality and dates / None] (Only list examinations personally reviewed. If none, state "None.")

Technique

[Exam approach, patient positioning, transducer type, and imaging modes used including grayscale and Doppler modalities as applicable; state whether study is limited or complete] (If technical limitations exist, state the cause, which structures were not adequately visualized, and impact on diagnostic confidence. If nondiagnostic for the clinical question, state this explicitly.)

Findings

[Organized anatomic findings by structure relevant to exam type and clinical question] (Describe appearance, echogenicity, contour, and focal abnormalities. Provide measurements in three dimensions with units for any abnormal findings. Include pertinent negatives relevant to the clinical question. Avoid "WNL" or "N/A"—if a structure is not visualized, state "not visualized" with the reason. When Doppler is performed, integrate flow characteristics, patency, waveform type, and quantitative parameters such as PSV, EDV, and RI where clinically relevant. Document explicit Doppler evidence supporting any vascular diagnosis.)

Impression

1. [Primary conclusion addressing the clinical question with key supporting measurement]
2. [Additional clinically significant finding if present]
3. [Study limitations and what cannot be excluded if applicable]
4. [Recommendation: follow-up timeframe, alternative modality, or clinical correlation if indicated]

(Provide 1–5 concise conclusions. Answer the clinical question first. Use definitive diagnoses when supported; otherwise state "indeterminate" with focused differential. Restate key measurements that drive management. Only include recommendations when actionable.)

Critical Communication (if applicable): [Person notified, date/time, method, confirmation of receipt] (Include only when findings require urgent action.)

Signature: [Interpreting clinician name and credentials]

Date/Time Finalized: [Date and time]