SonoSpot.com Recommendations for EMR smartphrases for Limited US Procedures

Limited Ultrasound EPIC SMARTPHRASES (until procedure template note created)

 

PROCEDURE: Limited ULTRASOUND - FAST scan

 

.EDUSFAST or .FAST

PROCEDURE: Limited ULTRASOUND - FAST scan (Limited Abdominal, Limited Echocardiography)

 

Additional views: Limited Thoracic for pneumothorax evaluation ***was/was not*** done

 

Indication/Medical Necessity:  ***   (physicians can select more than one from drop down)

Thoracic blunt trauma

Thoracic penetrating trauma

Abdominal blunt trauma

Abdominal penetrating trauma

Abdominal Pain, Right upper quadrant

Abdominal Pain, Left upper quadrant

Abdominal Pain, Right lower quadrant

Abdominal Pain, Left lower quadrant

Abdominal Pain, Epigastric

Abdominal Pain, Lower

Abdominal Pain, Middle

Pelvic pain

Flank Pain, Right

Flank Pain, Left                                                  

Upper back pain                                     

Lower back pain

Tachycardia        

Hypotension  

Shortness of Breath

Dyspnea

Hypoxia

Pregnancy

Altered Mental Status

Syncope/Near Syncope

Unconscious/Unresponsive

Cardiac Arrest                 

 

The right upper quadrant coronal plane evaluating the inferior right thoracic cavity, the hepatorenal space, and right paracolic gutter for anechoic free fluid was:

(drop down, can select more than one)

 *** NEGATIVE/POSITIVE*** FOR FREE FLUID IN INTRAPERITONEAL SPACE

***NEGATIVE/POSITIVE*** FOR FREE FLUID IN THORACIC CAVITY

INDETERMINATE

NOT DONE

A subcostal window of the heart evaluating for pericardial fluid was found to be: (drop down)

***POSITIVE   NEGATIVE        INDETERMINATE                               NOT DONE

Additional Cardiac views: A parasternal window of the heart ***was/was not required for improved visualization for pericardial fluid and found to be: (drop down)

***POSITIVE   NEGATIVE    INDETERMINATE                           NOT DONE

The left upper quadrant coronal plane evaluating the inferior left thoracic cavity, the splenorenal space, and left paracolic gutter for anechoic free fluid was:

(drop down, can select more than one)

 *** NEGATIVE/POSITIVE*** FOR FREE FLUID IN INTRAPERITONEAL SPACE

***NEGATIVE/POSITIVE*** FOR FREE FLUID IN THORACIC CAVITY

INDETERMINATE

NOT DONE

A suprapubic window evaluating posterior and lateral to the bladder for anechoic free fluid was:

***POSITIVE                  NEGATIVE  INDETERMINATE  NOT DONE

Additional views of thoracic region: The left and right upper anterior chest in para-sagittal planes ***was/was not*** evaluated using the linear probe. Between the 2nd and 3rd rib shadows, the pleural line was seen and evaluated for normal lung sliding or the presence of pneumothorax and found to be:

***NEGATIVE/POSITIVE*** FOR PNEUMOTHORAX ON LEFT SIDE  

***NEGATIVE/POSITIVE*** FOR PNEUMOTHORAX ON RIGHT SIDE        INDETERMINATE

NOT DONE

Overall Findings/Impression: (physicians to select more than one if necessary)

***NEGATIVE/POSITIVE*** FOR INTRAPERITONEAL FREE FLUID

***NEGATIVE/POSITIVE*** FOR INTRA-THORACIC FREE FLUID                  

***NEGATIVE/POSITIVE*** FOR RIGHT PNEUMOTHORAX

***NEGATIVE/POSITIVE*** FOR LEFT PNEUMOTHORAX  

***INDETERMINATE FOR PORTIONS OF EXAM STATED ABOVE

 

Other Findings/Comments: ***

***REPEAT EXAM BY ***SAME/DIFFERENT*** PHYSICIAN DUE TO CHANGE IN PATIENT STATUS: hemodynamic instability, falling hematocrit, increased abdominal pain, other ***

Further Imaging: (drop down -physician to select one if necessary)

***No clinical evidence requiring further imaging

*** clinical evidence requires further imaging,

***patient went for operative intervention due to hemodynamic instability and/or US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Abdominal Aorta scan

 

.EDUSAORTA or .USAORTA

PROCEDURE: Limited ULTRASOUND – Abdominal Aorta scan

Limited Retroperitoneal US

Indication/Medical necessity: ***(physicians can select more than one from drop down)

Abdominal Pain, Upper

Abdominal Pain, Lower

Abdominal Pain, Middle

Abdominal Pain, Right upper quadrant

Abdominal Pain, Left upper quadrant

Abdominal pain, Right lower quadrant

Abdominal Pain, Left lower quadrant

Chest pain

Back pain

Flank pain, Right

Flank Pain, Left

Syncope/Near-Syncope

Hypotension

Tachycardia

Pulsatile abdominal mass on exam

 

The abdominal aorta was evaluated in axial and sagittal planes from the celiac axis superiorly down to the level of the aortic bifurcation using the 3.5MHz probe.

 

In its largest diameter, the aorta measured : *** cm

 

The iliac vessels ***were/were not *** visualized and found to be ***normal/aneurysmal***

 

Overall Findings/Impression: (drop down)

***NORMAL ABDOMINAL AORTA  

ECTATIC ABDOMINAL AORTA  

ABDOMINAL AORTIC ANEURYSM

INDETERMINATE

 

If present, location of aneurysm was: *** SUPRARENAL  INFRARENAL   ILIAC             N/A

 

Further Imaging: (drop down -physician to select one if necessary)

***No clinical evidence requiring further imaging

***clinical evidence requires further imaging,

***patient went for operative intervention due to hemodynamic instability and/or US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Cardiac scan

 

.EDUSECHO and .USECHO

PROCEDURE: Limited ULTRASOUND – Cardiac scan

Limited Transthoracic Echocardiography

***Limited Retroperitoneal US ***was/was not*** performed to evaluate IVC diameter/respiratory variation for volume assessment

 

Indication/Medical necessity: *** (physicians can select more than one from drop down)

Cardiac Arrest

Tachypnea

Fever

Hypotension

Tachycardia

Chest pain

Shortness of breath

Dyspnea

Orthopnea

Palpitations

Chest wall blunt trauma

Syncope

Dehydration

Fluid overload

 

Using the phased array probe, a subcostal 4-chamber view of the heart ***was/was not*** obtained and demonstrated: *** (physicians can select more than one from drop down)

NORMAL CONTRACTILITY      

HYPERDYNAMIC  

HYPOKINESIS  

STANDSTILL

RA COLLAPSE  

RA DILATION  

RV COLLAPSE  

RV DILATION

RV HYPERTROPHY

LA COLLAPSE  

LA DILATION  

LV DILATION  

LV HYPERTROPHY

NO PERICARDIAL EFFUSION          

PERICARDIAL EFFUSION, TRACE

PERICARDIAL EFFUSION, MODERATE

PERICARDIAL EFFUSION, LARGE              

TAMPONADE

INDETERMINATE/POOR IMAGE QUALITY

NOT DONE

 

A parasternal long view of the heart ***was/was not** obtained and demonstrated: ***(physicians can select more than one from drop down)

NORMAL CONTRACTILITY    

HYPERDYNAMIC  

HYPOKINESIS  

STANDSTILL

RV COLLAPSE  

RV DILATION

RV HYPERTROPHY

LA COLLAPSE  

LA DILATION  

LV DILATION  

LV HYPERTROPHY

NO PERICARDIAL EFFUSION          

PERICARDIAL EFFUSION, TRACE

PERICARDIAL EFFUSION, MODERATE

PERICARDIAL EFFUSION, LARGE              

TAMPONADE

DILATED AORTIC ROOT  

NORMAL DESCENDING AORTA

ENLARGED DESCENDING AORTA

INDETERMINATE/POOR IMAGE QUALITY        

NOT DONE

***The thoracic aorta ***was/was not*** evaluated and measured: *** cm in its largest diameter

 

A Parasternal short view of the heart ***was/was not*** obtained and demonstrated: *** (physicians can select more than one from drop down)

NORMAL CONTRACTILITY      

HYPERDYNAMIC  

HYPOKINESIS    

STANDSTILL

RV COLLAPSE  

RV DILATION

RV HYPERTROPHY

LV DILATION  

LV HYPERTROPHY

D SHAPED LV

NO PERICARDIAL EFFUSION          

PERICARDIAL EFFUSION, TRACE

PERICARDIAL EFFUSION, MODERATE

PERICARDIAL EFFUSION, LARGE              

TAMPONADE

INDETERMINATE/POOR IMAGE QUALITY  

NOT DONE

 

An Apical 4-chamber view of the heart was obtained and demonstrated: *** (physicians can select more than one from drop down)

NORMAL CONTRACTILITY    

HYPERDYNAMIC  

HYPOKINESIS  

STANDSTILL

RA COLLAPSE  

RA DILATION  

RV COLLAPSE  

RV DILATION

RV HYPERTROPHY

LA COLLAPSE  

LA DILATION  

LV DILATION  

LV HYPERTROPHY

NO PERICARDIAL EFFUSION          

PERICARDIAL EFFUSION, TRACE

PERICARDIAL EFFUSION, MODERATE

PERICARDIAL EFFUSION, LARGE              

TAMPONADE

INDETERMINATE/POOR IMAGE QUALITY

NOT DONE

 

The inferior vena cava ***was/was not*** evaluated as it enters the right atrium and measured: *** cm in the maximal diameter and *** cm in minimal diameter in the region 2-3cm from the right atrial entrance and showed: *** (Physician can select only one)

<50% RESPIRATORY VARIATION  

>50% RESPIRATORY VARIATION  

NO RESPIRATORY VARIATION

INDETERMINATE/POOR IMAGE QUALITY

 

Overall Findings/Impression: ***(drop down - physician can select more than one if necessary)

NORMAL CONTRACTILITY  

HYPERDYNAMIC CONTRACTILITY

HYPOKINETIC CONTRACTILITY

CARDIAC STANDSTILL

RV DILATION

RV STRAIN

RV HYPERTROPHY  

RA DILATION

LV DILATION

LV HYPERTROPHY  

LA DILATION

NO EVIDENCE OF THOARCIC AORTIC ANEURYSM        

THORACIC AORTIC ANEURYSM

THORACIC AORTIC DISSECTION

NO PERICARDIAL EFFUSION

PERICARDIAL EFFUSION        

TAMPONADE

NORMAL IVC        

HYPOVOLEMIA PER IVC MEASUREMENT          

HYPERVOLEMIA PER IVC MEASUREMENT              

INDETERMINATE

 

Further Imaging: (drop down - physician to select one if necessary)

*** No clinical evidence requiring further imaging

*** clinical evidence requires further imaging,

***patient went for operative intervention due to hemodynamic instability and US findings

Other Comments: (free text)

 

***REPEAT EXAM BY ***SAME/DIFFERENT*** PHYSICIAN DUE TO CHANGE IN PATIENT STATUS: hemodynamic instability, falling hematocrit, increased abdominal pain, other ***

 

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – IVC scan

 

.EDUSIVC and .USIVC

Procedure: Limited ULTRASOUND – IVC scan

Limited Retroperitoneal US

Indication/Medical necessity: *** (physicians can select more than one)

Hypotension

Tachycardia

Chest pain

Shortness of breath

Dyspnea

Orthopnea

Palpitations

Syncope

Fever

 

Using the phased array probe, the inferior vena cava was evaluated as it enters the right atrium and measured: *** cm in the maximal diameter and *** cm in minimal diameter in the region 2-3cm from the right atrial entrance and showed: *** (physician to select only one)

<50% RESPIRATORY VARIATION  

>50% RESPIRATORY VARIATION  

NO RESPIRATORY VARIATION

POOR IMAGE QUALITY

 

Overall Findings/Impression: ***(drop down - physician to select one if necessary)

NORMAL IVC        

HYPOVOLEMIA          

HYPERVOLEMIA      

INDETERMINATE

 

Further Imaging: (drop down - physician to select one if necessary)

*** No clinical evidence requiring further imaging

*** Clinical evidence requires further imaging

*** Patient went for operative intervention due to hemodynamic instability and US findings

Other Comments:

*** REPEAT EXAM BY ***SAME/DIFFERENT*** PHYSICIAN DUE TO CHANGE IN PATIENT STATUS: hemodynamic instability, new shortness of breath, hypoxia, other ***

 

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Thoracic/Chest scan

 

.EDUSTHORACIC and .USTHORACIC

Limited Thoracic US

Indication/Medical necessity: *** (physicians can select more than one)

Dyspnea

Orthopnea

Shortness of breath

Chest pain

Hypoxia

Hypotension

Tachycardia

Blunt thoracic trauma

Penetrating thoracic trauma

 

***The right upper anterior chest in para-sagittal planes using the linear probe was evaluated. Between the 2nd and 3rd rib shadows, the pleural line was seen and evaluated for lung sliding or the presence of pneumothorax and found to be: (physicians can select one)

***NEGATIVE/POSITIVE*** FOR PNEUMOTHORAX                

***INDETERMINATE

 

***The left upper anterior chest in para-sagittal planes using the linear probe was evaluated. Between the 2nd and 3rd rib shadows, the pleural line was seen and evaluated for lung sliding or the presence of pneumothorax and found to be: (physicians can select one)

***NEGATIVE/POSITIVE*** FOR PNEUMOTHORAX                

***INDETERMINATE

 

***The right chest ***was/was not*** evaluated in four quadrants using the phased array probe and the pleural line and interstitium was seen and demonstrated: ***(physicians can select one)

NORMAL LUNG SLIDING

A LINES  

LESS THAN TWO B LINES IN ALL QUADRANTS

GREATER THAN 2 B LINES in ONE QUADRANT        

GREATER THAN TWO B LINES in TWO QUADRANTS  

GREATER THAN TWO B LINES in THREE QUADRANTS  

GREATER THAN TWO B LINES in FOUR QUADRANTS

B LINES WITH SPARED AREAS

 

***The left chest was evaluated in four quadrants using the phased array probe and the pleural line and interstitium was seen and demonstrated: *** (physicians can select one)

NORMAL LUNG SLIDING        

A LINES

LESS THAN TWO B LINES IN ALL QUADRANTS

GREATER THAN 2 B LINES in ONE QUADRANT        

GREATER THAN TWO B LINES in TWO QUADRANTS

GREATER THAN TWO B LINES in THREE QUADRANTS  

GREATER THAN TWO B LINES in FOUR QUADRANTS

B LINES WITH SPARED AREAS

 

***The right lower thoracic cavity in coronal plane using the phased array probe was evaluated for anechoic free fluid and found to be: *** physicians can select one)

POSITIVE   NEGATIVE   INDETERMINATE

***The left lower thoracic cavity in coronal plane using the phased array probe was evaluated for anechoic free fluid and found to be: *** physicians can select one)

POSITIVE   NEGATIVE   INDETERMINATE

 

Overall Findings/Impression: *** (physicians can select more than one)

POSITIVE FOR PNEUMOTHORAX ON RIGHT SIDE

POSITIVE PNEUMOTHORAX ON LEFT SIDE

NEGATIVE FOR PNEUMOTHORAX

POSITIVE FOR DIFFUSE ALVEOLAR INTERSTITIAL SYNDROME

POSITIVE FOR FOCAL ALVEOLAR INTERSTITIAL SYNDROME

NEGATIVE FOR ALVEOLAR INTERSTITIAL SYNDROME

POSITIVE FOR RIGHT PLEURAL EFFUSION

POSITIVE FOR LEFT PLERUAL EFFUSION

NEGATIVE FOR PLEURAL EFFUSIONS

Other comments: ***

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

*** REPEAT EXAM BY ***SAME/DIFFERENT*** PHYSICIAN DUE TO CHANGE IN PATIENT STATUS: hemodynamic instability, new shortness of breath, hypoxia, other ***

 

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Gallbladder scan

 

.EDUSGALLBLADDER and .USGALLBLADDER

Limited Abdominal US

Indication/Medical necessity:*** (physicians can select more than one)

Abnormal labs

Abdominal pain, right upper quadrant

Abdominal pain, epigastric region

Abdominal pain, generalized

Abdominal tenderness, right upper quadrant

Abdominal tenderness, epigastric region

Abdominal tenderness, generalized

Flank Pain, Right

Back Pain

Jaundice

Fever

 

Using the 3.5MHz probe, longitudinal and transverse views of the gallbladder were evaluated and revealed:

***NO GALLSTONES        

SINGLE GALLSTONE        

MULTIPLE GALLSTONES

SLUDGE  

POLYP

INDETERMINATE

***The anterior gallbladder wall measured: *** mm

***The common bile duct measured: *** mm

***The gallbladder width measured: *** cm

***The gallbladder length measured: *** cm

Pericholecystic fluid is ***absent/present

Sonographic Murphy’s sign is ***absent/present

 

Overall Findings/Impression:*** physicians can select one from drop down)

NORMAL GALLBLADDER, NEGATIVE FOR GALLSTONES

POSITIVE FOR GALLSTONES WITHOUT EVIDENCE OF CHOLECYSTITIS

POSITIVE FOR CHOLECYSTITIS

SLUDGE

GALLBLADDER POLYP

DILATED GALLBLADDER

Other comments: ***

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Renal/Urinary Tract scan

 

.EDUSRENAL and .USRENAL

Procedure: Limited ULTRASOUND – Renal/Urinary Tract US

Limited Retroperitoneal US

Indication/Medical necessity: *** (physicians can select more than one)

Abdominal pain, Right upper quadrant

Abdominal pain, Left upper quadrant

Abdominal pain, Right lower quadrant

Abdominal pain, Left lower quadrant

Flank pain, Right

Flank pain, Left

Back pain

Hematuria

Urinary retention

Dysuria

Acute renal failure

Anuria

Post-void

Fever

 

Using the 3.5 MHz probe, coronal and transverse planes of the right kidney were obtained and found to have:  ***  (physicians to select one)

POSITIVE FOR HYDRONEPHROSIS  

NEGATIVE FOR HYDRONEPHROSIS  

INTRARENAL KIDNEY STONE  

RENAL CYST

INTRAPERITONEAL FREE FLUID

INDETERMINATE

 

The coronal and transverse planes of the left kidney were obtained and found to have: ***:  (physicians to select one)

POSITIVE FOR HYDRONEPHROSIS  

NEGATIVE FOR HYDRONEPHROSIS  

INTRARENAL KIDNEY STONE  

RENAL CYST

INTRAPERITONEAL FREE FLUID

INDETERMINATE

 

The transverse and sagittal bladder was evaluated and showed: ***:  (physicians to select one)

NORMAL CONTOUR  

BLADDER DISTENSION        

BLADDER COLLAPSE

BLADDER MASS

***Bladder volume measurement ***was/was not***obtained by calculating the width, length and height using the ultrasound machine’s calculation function and found to be: *** mL

 

Overall Findings/Impression:*** :  (physicians to select one)

NEGATIVE FOR HYDRONEPHROSIS

POSITIVE FOR RIGHT SIDED MILD HYDRONEPHROSIS

POSITIVE FOR RIGHT SIDED MODERATE HYDRONEPHROSIS

POSITIVE FOR RIGHT SIDED SEVERE HYDRONEPHROSIS

POSITIVE FOR LEFT SIDED MILD HYDRONEPHROSIS

POSITIVE FOR LEFT SIDED MODERATE HYDRONEPHROSIS

POSITIVE FOR LEFT SIDED SEVERE HYDRONEPHROSIS

INTRARENAL KIDNEY STONE

RENAL CYST

INTRAPERITONEAL FREE FLUID

NORMAL BLADDER

BLADDER DISTENSION

BLADDER COLLAPSED

BLADDER MASS

Other Findings/comments: ***

 

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Bladder and volume

 

.EDUSBLADDER and .USBLADDER

Procedure: Limited ULTRASOUND – Bladder US

Limited Bladder US

Indication/Medical necessity: *** (physicians can select more than one)

Abdominal pain, lower

Abdominal tenderness, right lower quadrant

Abdominal tenderness, Left lower quadrant

Abdominal tenderness, suprapubic

Right Flank pain

Left Flank pain

Back pain

Hematuria

Urinary retention

Dysuria

Incontinence

Acute renal failure

Anuria

Post-void

Fever

 

The transverse and sagittal bladder was evaluated and showed: ***

NORMAL CONTOUR  

BLADDER DISTENSION        

BLADDER COLLAPSE

BLADDER MASS

INDETERMINATE

 

Bladder volume measurement obtained by calculating the width, length and height using the ultrasound machine’s calculation function and found to be: *** mL

 

***The Prostate was seen and measured: *** cm in largest diameter

 

Overall Findings/Impression:*** physicians can select one

NORMAL BLADDER

BLADDER MASS

BLADDER DISTENSION

BLADDER COLLAPSED

ENLARGED PROSTATE

Other findings/comments: ***

 

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – BladderScanner for Volume scan

 

.EDUSBLADDERSCANNER

Procedure: Limited ULTRASOUND – BladderScanner for Volume US

Limited BladderScanner US (no recorded images necessary)

Indication/Medical necessity: *** (physicians can select more than one)

Abdominal pain, lower

Abdominal tenderness, right lower quadrant

Abdominal tenderness, Left lower quadrant

Abdominal tenderness, suprapubic

Right Flank pain

Left Flank pain

Back pain

Hematuria

Urinary retention

Dysuria

Incontinence

Acute renal failure

Anuria

Post-void

Bladder volume measurement obtained by the BladderScanner calculation function and found to be: *** mL

 

Overall Findings/Impression: bladder volume *** mL

Other comments: ***

 

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Transabdomial Pelvic scan for Pregnancy

 

.EDUSTAPELVICPREGNANT and .USTAPELVICPREGNANT

Procedure: Limited ULTRASOUND – Transabdominal Pelvic Scan for Pregnancy

Limited Transabdominal Pregnant Pelvic US

Indication/Medical necessity: *** (physicians can select more than one)

Positive pregnancy test

Missed menstrual cycle

Abdominal pain, right upper quadrant

Abdominal pain, left upper quadrant

Abdominal pain, right lower quadrant

Abdominal pain, left lower quadrant

Abdominal pain, lower

Back pain

Pelvic pain

Vaginal Bleeding

Syncope

Hypotension

Tachycardia

Decreased Fetal Movement

Trauma

 

Using the 3.5 MHz probe, the transverse and sagittal views of the entire uterus was evaluated including all internal echoes and showed: *** (physicians to select one)

NO INTRAUTERINE PREGNANCY

EMPTY GESTATIONAL SAC WITHIN THE ENDOMETRIAL ECHO OF THE UTERUS

GESTATIONAL SAC WITHIN THE ENDOMETRIAL ECHO OF THE UTERUS WITH YOLK SAC

GESTATIONAL SAC WITHIN ENDOMETRIAL ECHO OF UTERUS WITH FETAL POLE WITHOUT FETAL CARDIAC ACTIVITY

GESTATIONAL SAC WITHING ENDOMETRIAL ECHO OF UTERUS WITH FETAL POLE AND FETAL CARDIAC ACTIVITY

FREE INTRAPERITONEAL FLUID IN PELVIC CAVITY

INDETERMINATE

 

***The fetal heart rate was evaluated or measured using M-mode and calculated to be: *** bpm

 

***The right adnexal region ***was/was not*** evaluated to visualize the right ovary in coronal view and showed: physician to select one)

NORMAL CONTOUR  

OVARIAN CYST  

OVARIAN MASS  

ECTOPIC PREGNANCY  

POOR IMAGE QUALITY

INABILITY TO VISUALIZE

*** The left adnexal region *** was/was not*** evaluated to visualize the left ovary in coronal view and showed: physician to select one)

NORMAL CONTOUR  

OVARIAN CYST  

OVARIAN MASS  

ECTOPIC PREGNANCY  

POOR IMAGE QUALITY

INABILITY TO VISUALIZE

 

Overall Findings/Impression: *** physician to select one from drop down)

LIVE INTRAUTERINE PREGNANCY

INTRAUTERINE PREGNANCY WITH NORMAL FETAL HEART RATE

INTRAUTERINE PREGNANCY WITH ABNORMAL FETAL HEART RATE

MOLAR PREGNANCY

FETAL DEMISE

NO DEFINITE INTRAUTERINE PREGNANCY

ABNORMAL INTRAUTERINE PREGNANCY

DEFINITE ECTOPIC PREGNANCY

Other comments: ***

 

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Transvaginal Pelvic scan for Pregnancy

 

.EDUSTVPELVICPREGNANT and .USTVPELVICPREGNANT

Procedure: Limited ULTRASOUND – Transvaginal Pelvic Scan for Pregnancy

Limited Transvaginal Pregnant Pelvic US

Indication/Medical necessity: *** (physicians can select more than one)

Positive pregnancy test

Missed menstrual cycle

Abdominal pain, right upper quadrant

Abdominal pain, left upper quadrant

Abdominal pain, right lower quadrant

Abdominal pain, left lower quadrant

Abdominal pain, lower

Back pain

Pelvic pain

Vaginal Bleeding

Syncope

Hypotension

Tachycardia

Decreased Fetal Movement

Trauma

 

Using the 7.0 MHz endocavitary probe, the coronal and sagittal views of the entire uterus was evaluated including all internal echoes and showed: *** (physician can select more than one)

NO INTRAUTERINE PREGNANCY

EMPTY GESTATIONAL SAC WITHIN THE ENDOMETRIAL ECHO OF THE UTERUS

GESTATIONAL SAC WITHIN THE ENDOMETRIAL ECHO OF THE UTERUS WITH YOLK SAC

GESTATIONAL SAC WITHIN ENDOMETRIAL ECHO OF UTERUS WITH FETAL POLE WITHOUT FETAL CARDIAC ACTIVITY

GESTATIONAL SAC WITHIN ENDOMETRIAL ECHO OF UTERUS WITH FETAL POLE AND FETAL CARDIAC ACTIVITY

FREE INTRAPERITONEAL FLUID IN PELVIC CAVITY

INDETERMINATE

 

*** The fetal heart rate was evaluated or measured using M-mode and calculated to be: *** bpm

 

***The right adnexal region ***was/was not*** evaluated to visualize the right ovary in coronal view and showed: (physician to select one)

NORMAL CONTOUR  

OVARIAN CYST  

OVARIAN MASS  

ECTOPIC PREGNANCY

POOR IMAGE QUALITY

INABILITY TO VISUALIZE

***The left adnexal region ***was/was not*** evaluated to visualize the left ovary in coronal view and showed: (physician to select one)

NORMAL CONTOUR  

OVARIAN CYST  

OVARIAN MASS  

ECTOPIC PREGNANCY

POOR IMAGE QUALITY

INABILITY TO VISUALIZE

 

Overall Findings/Impression: ***(physician to select one)

LIVE INTRAUTERINE PREGNANCY

INTRAUTERINE PREGNANCY WITH NORMAL FETAL HEART RATE

INTRAUTERINE PREGNANCY WITH ABNORMAL FETAL HEART RATE

MOLAR PREGNANCY

FETAL DEMISE

NO DEFINITE INTRAUTERINE PREGNANCY

ABNORMAL INTRAUTERINE PREGNANCY

DEFINITE ECTOPIC PREGNANCY

Other findings/comments: ***

 

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Transabdomial Pelvic scan, NonPregnant

 

.EDUSTAPELVICNONPREGNANT and .USTAPELVICNONPREGNANT

Procedure: Limited ULTRASOUND – Transabdominal Pelvic Scan, NonPregnant

Limited Transabdominal NonObstetric Pelvic US

Indication/Medical necessity: *** (physicians can select more than one)

Abdominal pain, right upper quadrant

Abdominal pain, left upper quadrant

Abdominal pain, right lower quadrant

Abdominal pain, left lower quadrant

Abdominal pain, upper

Abdominal pain, lower

Abdominal tenderness, Left lower quadrant

Abdominal tenderness, Right lower quadrant

Back pain

Pelvic pain

Vaginal Bleeding

Syncope

Hypotension

Tachycardia

Urinary retention

Dysuria

Hematuria

Trauma

 

Using the 3.5 MHz probe, the transverse and sagittal views of the entire pelvic cavity was evaluated including all pelvic organs and internal echoes and showed:  *** physicians can select more than one)

NORMAL UTERINE CONTOUR

ABNORMAL UTERINE CONTOUR

UTERINE MASS

FREE INTRAPERITONEAL FLUID IN PELVIC CAVITY

EMPTY GESTATIONAL SAC WITHIN THE ENDOMETRIAL ECHO OF THE UTERUS

GESTATIONAL SAC WITHIN THE ENDOMETRIAL ECHO OF THE UTERUS WITH YOLK SAC

GESTATIONAL SAC WITHIN ENDOMETRIAL ECHO OF UTERUS WITH FETAL POLE WITHOUT FETAL CARDIAC ACTIVITY

GESTATIONAL SAC WITHING ENDOMETRIAL ECHO OF UTERUS WITH FETAL POLE WITH FETAL CARDIAC ACTIVITY

INDETERMINATE

 

The endometrial stripe measured: *** mm

The Prostate was measured: *** mm

 

***The right adnexal region ***was/was not*** evaluated to visualize the right ovary in coronal view and showed: physicians can select one)

NORMAL CONTOUR  

OVARIAN CYST  

OVARIAN MASS  

ECTOPIC PREGNANCY  

POOR IMAGE QUALITY

INABILITY TO VISUALIZE

***The left adnexal region ***was/was not*** evaluated to visualize the left ovary in coronal view and showed: physicians can select one)

NORMAL CONTOUR  

OVARIAN CYST  

OVARIAN MASS  

ECTOPIC PREGNANCY

POOR IMAGE QUALITY

INABILITY TO VISUALIZE

 

Overall Findings/Impression: *** physicians can select more than one)

NO SONOGRAPHIC EVIDENCE FOR ABOVE SYMPTOMS

NORMAL PROSTATE

ENLARGED PROSTATE

NORMAL UTERINE CONTOUR

NORMAL RIGHT OVARY

NORMAL LEFT OVARY

THICKENED ENDOMETRIAL STRIPE

UTERINE MASS

OVARIAN CYST, RIGHT

OVARIAN CYST, LEFT

ADNEXAL MASS, RIGHT

ADNEXAL MASS, LEFT

FREE INTRAPERITONEAL FLUID IN PELVIC CAVITY

LIVE INTRAUTERINE PREGNANCY

INTRAUTERINE PREGNANCY WITH NORMAL FETAL HEART RATE

INTRAUTERINE PREGNANCY WITH ABNORMAL FETAL HEART RATE

ABNORMAL INTRAUTERINE PREGNANCY

DEFINITE ECTOPIC PREGNANCY

Other findings/comments: ***

 

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Transvaginal Pelvic scan, Nonpregnant

 

.EDUSTVPELVICNONPREGNANT and .USTVPELVICNONPREGNANT

Procedure: Limited ULTRASOUND – Transvaginal Pelvic Scan, Nonpregnant

Limited Transvaginal NonObstetric Pelvic US

Indication/Medical necessity: *** (physicians can select more than one)

Abdominal pain, right upper quadrant

Abdominal pain, left upper quadrant

Abdominal pain, right lower quadrant

Abdominal pain, left lower quadrant

Abdominal pain, upper

Abdominal pain, lower

Abdominal tenderness, Left lower quadrant

Abdominal tenderness, Right lower quadrant

Back pain

Pelvic pain

Vaginal Bleeding

Syncope

Hypotension

Tachycardia

Urinary retention

Dysuria

Hematuria

Trauma

 

Using the 7.0 MHz endocavitary probe, the coronal and sagittal views of the entire uterus was evaluated including all internal echoes and showed: ***

NORMAL UTERINE CONTOUR

ABNORMAL UTERINE CONTOUR

UTERINE MASS

FREE INTRAPERITONEAL FLUID IN PELVIC CAVITY

EMPTY GESTATIONAL SAC WITHIN THE ENDOMETRIAL ECHO OF THE UTERUS

GESTATIONAL SAC WITHIN THE ENDOMETRIAL ECHO OF THE UTERUS WITH YOLK SAC

GESTATIONAL SAC WITHIN ENDOMETRIAL ECHO OF UTERUS WITH FETAL POLE WITHOUT FETAL CARDIAC ACTIVITY

GESTATIONAL SAC WITHING ENDOMETRIAL ECHO OF UTERUS WITH FETAL POLE WITH FETAL CARDIAC ACTIVITY

INDETERMINATE

The Endometrial stripe measured: *** mm

 

***The right adnexal region was evaluated to visualize the right ovary in coronal view and showed: physicians can select one):

NORMAL CONTOUR  

OVARIAN CYST  

OVARIAN MASS  

ECTOPIC PREGNANCY

POOR IMAGE QUALITY

INABILITY TO VISUALIZE

***The left adnexal region was evaluated to visualize the left ovary in coronal view and showed: physicians can select one):

NORMAL CONTOUR  

OVARIAN CYST  

OVARIAN MASS  

ECTOPIC PREGNANCY

POOR IMAGE QUALITY

INABILITY TO VISUALIZE

 

***The right ovary was then evaluated using color duplex doppler and showed ***normal/no arterial and venous flow***

*** The left ovary was then evaluated using color duplex Doppler and showed ***normal/no arterial and venous flow***

 

Overall Findings/Impression: *** (physician to select more than one)

NO SONOGRAPHIC EVIDENCE FOR ABOVE SYMPTOMS

NORMAL UTERINE CONTOUR

NORMAL RIGHT OVARY

NORMAL LEFT OVARY

THICKENED ENDOMETRIAL STRIPE

UTERINE MASS

OVARIAN CYST, RIGHT

OVARIAN CYST, LEFT

OVARIAN TORSION, RIGHT

OVARIAN TORSION, LEFT

ADNEXAL MASS, RIGHT

ADNEXAL MASS, LEFT

FREE INTRAPERITONEAL FLUID IN PELVIC CAVITY

LIVE INTRAUTERINE PREGNANCY

INTRAUTERINE PREGNANCY WITH NORMAL FETAL HEART RATE

INTRAUTERINE PREGNANCY WITH ABNORMAL FETAL HEART RATE

DEFINITE ECTOPIC PREGNANCY

Other findings/comments: ***

 

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Scrotal scan

 

.EDUSSCROTAL and .USSCROTAL

Procedure: Limited ULTRASOUND – Scrotal Scan for Mass/Torsion

Limited Scrotal US

Indication/Medical necessity: *** (physicians can select more than one)

Abdominal pain, right lower quadrant

Abdominal pain, left lower quadrant

Abdominal pain, lower

Back pain

Pelvic pain

Testicular pain, left

Testicular pain, right

Testicular tenderness, left

Testicular tenderness, right

Testicular Trauma

 

Using the linear array probe, the transverse and sagittal views of each hemi-scrotal sac was evaluated including all internal echoes of each testicle and showed: ***(physicians can select more than one)

NORMAL TESTICULAR CONTOUR, SIZE and LIE WITHOUT ADJACENT FLUID COLLECTION

NO HYPEREMIA

HYPEREMIA OF TESTICLE, RIGHT

HYPEREMIA OF TESTICLE, LEFT

HYDROCELE, RIGHT

HYDROCELE, LEFT

VARICOCELE, RIGHT

VARICOCELE, LEFT

TESTICULAR MASS, RIGHT

TESTICULAR MASS, LEFT

 

***The right testicle was then evaluated using color duplex doppler with arterial and venous flow being: physicians can select one)

ABSENT

PRESENT

INDETERMINATE

*** The left testicle was then evaluated using color duplex doppler with arterial and venous flow being: physicians can select one)

ABSENT

PRESENT

INDETERMINATE

 

Overall Findings/Impression: *** physicians can select one)

NO SONOGRAPHIC EVIDENCE FOR ABOVE SYMPTOMS

SONOGRAPHIC EVIDENCE SUGGESTIVE FOR TORSION, RIGHT

SONOGRAPHIC EVIDENCE SUGGESTIVE FOR TORSION, LEFT

TESTICULAR MASS, RIGHT

TESTICULAR MASS, LEFT

HYDROCELE, RIGHT

HYDROCELE, LEFT

VARICOCELE, RIGHT

VARICOCELE, LEFT

ORCHITIS, RIGHT

ORCHITIS, LEFT

Other findings/comments: ***

 

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – DVT scan

 

.EDUSDVT and .USDVT

Procedure: Limited ULTRASOUND – Lower extremity DVT Scan

Limited DVT US

Indication/Medical necessity: *** (physicians can select more than one)

Right leg swelling

Left leg swelling

Right leg pain

Left leg pain

Right leg redness

Left leg redness

Dyspnea

Orthopnea

Tachypnea

Hypoxia

Shortness of breath

Chest pain, pleuritic

 

Using the 5.0MHz linear probe:

***The transverse view of the right common femoral vein was evaluated at the level of the inguinal ligament and 10cm distally. At 1cm increments, the vein demonstrated : *** physicians can select one)

FULL COMPRESSION        

PARTIAL COMPRESSION  

NO COMPRESSION

INDETERMINATE

***The transverse view of the left common femoral vein was evaluated at the level of the inguinal ligament and 10cm distally. At 1cm increments, the vein demonstrated : *** physicians can select one)

FULL COMPRESSION        

PARTIAL COMPRESSION  

NO COMPRESSION

INDETERMINATE

***The transverse view of the right popliteal vein was evaluated at the level of the popliteal fossa to its trifurcation for a total of 5cm along its length. At 1cm increments, the vein demonstrated : *** physicians can select one)

FULL COMPRESSION        

PARTIAL COMPRESSION  

NO COMPRESSION

INDETERMINATE

***The transverse view of the left popliteal vein was evaluated at the level of the popliteal fossa to its trifurcation for a total of 5cm along its length. At 1cm increments, the vein demonstrated : *** physicians can select one)

FULL COMPRESSION        

PARTIAL COMPRESSION  

NO COMPRESSION

INDETERMINATE

 

Overall Findings/Impression: ***

NO EVIDENCE OF DVT IN RIGHT LEG

NO EVIDENCE OF DVT IN LEFT LEG

DVT IN RIGHT LEG, FEMORAL

DVT IN RIGHT LEG, POPLITEAL

DVT IN LEFT LEG, FEMORAL

DVT IN LEFT LEG, POPLITEAL

INDETERMINATE

Other findings/comments: ***

 

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Soft Tissue - ABSCESS evaluation

 

.EDUSSOFTTISSUE

Procedure: Limited ULTRASOUND – Soft Tissue Scan for Abscess evaluation

Limited Soft Tissue US

Indication/Medical necessity: *** (physicians can select more than one)

Skin Swelling

Skin Redness

Pain

Mass

Fever

Decreased range of motion

 

Location: ***(physicians can select more than one from drop down)

Peritonsillar

Neck

Axilla

Chest wall

Breast

Upper back

Lower back

Abdominal wall

Pelvic wall

Right Upper Extremity

Left Upper Extremity

Right Lower Extremity

Left Lower Extremity

 

Using the linear probe: the area of skin in question showing the above signs was evaluated and showed:

NORMAL SKIN AND SUBCUTANEOUS ECHOGENICITY

COBBLESTONING WITHOUT SUBCUTANEOUS FLUID COLLECTION

COBBLESTONING WITH SUBCUTANEOUS FLUID COLLECTION

SUBCUTANEOUS FLUID COLLECTION

SOFT TISSUE SOLID MASS

 

*** The size of the subcutaneous fluid collection measured: ***cm

 

Using the linear probe covered in a sterile sheath, the abscess ***was/was not*** localized for incision and drainage after seen to contain hypoechoic debris

 

Overall Findings/Impression: ******(physicians can select more than one from drop down)

NO SONOGRAPHIC EVIDENCE OF CELLULITIS OR ABSCESS

NO SONOGRAPHIC EVIDENCE OF ABSCESS

SONOGRAPHIC EVIDENCE OF CELLULITIS

SONOGRAPHIC EVIDENCE OF ABSCESS

NORMAL LYMPH NODE

ENLARGED LYMPH NODE

SOFT TISSUE SOLID MASS

INDETERMINATE

 

***Location: ***(free text)

 

Other comments: ***

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Soft Tissue – Foreign Body evaluation

Limited Soft Tissue US

 

.EDUSFOREIGNBODY

Procedure: Limited ULTRASOUND – Soft Tissue Scan for Foreign Body evaluation

Limited Soft Tissue US

Indication/Medical necessity: *** (physicians can select more than one)

Skin Swelling

Skin Redness

Pain

Mass

Fever

Decreased range of motion

 

Location: ***

Neck

Axilla

Chest wall

Breast

Upper back

Lower back

Abdominal wall

Pelvic wall

Right Upper Extremity

Left Upper Extremity

Right Lower Extremity

Left Lower Extremity

 

Using the linear probe: the area of skin in question showing the above signs was evaluated and showed: (physicians can select more than one from drop down)

NORMAL SKIN AND SUBCUTANEOUS ECHOGENICITY

COBBLESTONING WITHOUT SUBCUTANEOUS FLUID COLLECTION

COBBLESTONING WITH SUBCUTANEOUS FLUID COLLECTION

SUBCUTANEOUS FLUID COLLECTION

FOREIGN BODY

 

*** The size of the foreign body measured: (free text) cm

 

Using the linear probe covered in a sterile sheath, the foreign body ***was/was not*** localized for incision and removal

 

Overall Findings/Impression: ***(physicians can select more than one)

FOREIGN BODY

NO SONOGRAPHIC EVIDENCE OF FOREIGN BODY

NO SONOGRAPHIC EVIDENCE OF ABSCESS

NO SONOGRAPHIC EVIDENCE OF CELLULITIS

SONOGRAPHIC EVIDENCE OF FOREIGN BODY

SONOGRAPHIC EVIDENCE OF ABSCESS

NORMAL LYMPH NODE

ENLARGED LYMPH NODE

INDETERMINATE

 

Shape and Location: ***

 

Other comments: ***

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Soft Tissue – Musculoskeletal injury

 

.EDUSMSK

Procedure: Limited ULTRASOUND – Soft Tissue Scan for Musculoskeletal injury

Limited Soft Tissue US

Indication/Medical necessity: *** (physicians can select more than one)

Swelling

Redness

Pain

Mass

Fever

Decreased range of motion

 

Location: ***

Neck

Axilla

Chest wall

Upper back

Lower back

Abdominal wall

Right Upper Extremity

Left Upper Extremity

Right Lower Extremity

Left Lower Extremity

Using the linear probe: the area of skin in question showing the above signs was evaluated and showed: ***(drop down -physician to select one if necessary)

NORMAL SKIN, SUBCUTANEOUS, AND MUSCULOSKELETAL ECHOGENICITY

THICKENED TENDON WITH SURROUNDING FLUID

CORTICAL BREAK IN BONE

SUBCUTANEOUS FLUID COLLECTION

FOREIGN BODY

Overall Findings/Impression: ***(drop down -physician to select more than)

NO SONOGRAPHIC EVIDENCE OF MUSCULOSKELETAL INJURY

SONOGRAPHIC EVIDENCE OF FRACTURE

SONOGRAPHIC EVIDENCE OF FLUID COLLECTION OR HEMATOMA

SONOGRAPHIC EVIDENCE OF TENDONITIS

INDETERMINATE

Location: ***

Other comments: ***

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURE: Limited ULTRASOUND – Ocular US

Limited Ocular US

 

.EDUSOCULAR

Procedure: Limited ULTRASOUND – Ocular US

Limited Ocular US

Indication/Medical necessity: *** (physicians can select more than one)

Right Eye pain

Left eye pain

Right Eye/Orbital trauma

Left Eye/Orbital trauma

Right Eye swelling

Left Eye swelling

Right Vision change

Left Vision change

Right Vision loss

Left Vision loss

Headache

Head injury

 

Using the high frequency linear probe, sagittal and transverse views of both eyes were obtained evaluating the anterior chamber, posterior chamber, retinal contour, lens location, and overall orbital structure.

 

Right eye:

The anterior chamber was: *** (physicians can select one from drop down)

INTACT        

RUPTURED  

INDETERMINATE

The posterior chamber appeared: *** (physicians can select one from drop down)

INTACT        

RUPTURED  

INDETERMINATE

The vitreous body appeared: *** (physicians can select one from drop down)

ANECHOIC  

HYPERECHOIC DENSITY  

INDETERMINATE

The lens was: *** (physicians can select one from drop down)

NORMALLY LOCATED  

DISLODGED        

INDETERMINATE

The retinal contour was: *** (physicians can select one from drop down)

NORMAL  

DETACHED        

INDETERMINATE

 

There ***was/was no*** evidence of hemorrhage.

The region posterior to the eye ***had/had no*** evidence of retrobulbar hematoma

The optic nerve sheath diameter ***was/was not***measured : *** mm at the region 3mm from the posterior orbit

 

Left eye:

The anterior chamber was: *** (physicians can select one from drop down)

INTACT        

RUPTURED  

INDETERMINATE

The posterior chamber appeared: *** (physicians can select one from drop down)

INTACT        

RUPTURED  

INDETERMINATE

The vitreous body appeared: *** (physicians can select one from drop down)

ANECHOIC  

HYPERECHOIC DENSITY  

INDETERMINATE

The lens was: *** (physicians can select one from drop down)

NORMALLY LOCATED  

DISLODGED        

INDETERMINATE

The retinal contour was: *** (physicians can select one from drop down)

NORMAL  

DETACHED        

INDETERMINATE

 

There ***was/was no*** evidence of hemorrhage.

The region posterior to the eye ***had/had no*** evidence of retrobulbar hematoma

The optic nerve sheath diameter ***was/was not***measured : *** mm at the region 3mm from the posterior orbit

 

Overall Findings/Impression: *** physicians can select one from drop down)

NO ACUTE ABNORMALITIES IDENTIFIED, Right eye

NO ACUTE ABNORMALITIES IDENTIFIED, Left eye

RETINAL DETACHMENT, Right eye

RETINAL DETACHMENT, Left eye

LENS DISLOCATION, Right eye

LENS DISLCOATION, Left eye

VITREOUS HEMORRHAGE, Right eye

VITREOUS HEMORRHAGE, Left eye

INTRAOCULAR FOREIGN BODY, Right eye

INTRAOCULAR FOREIGN BODY, Left eye

EXTRAOCULAR FOREIGN BODY, Right eye

EXTRAOCULAR FOREIGN BODY, Left eye

GLOBE RUPTURE, Right eye

GLOBE RUPTURE, Left eye

INCREASED ONSD, Right eye

INCREASED ONSD, Left eye

INDETERMINATE

 

Other findings/comments: ***

Further Imaging: (physicians can select one from drop down)

***No clinical evidence requiring further imaging

***Clinical evidence requires further imaging,

***Patient needs operative intervention due to hemodynamic instability and US findings

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

PROCEDURAL ULTRASOUND

 

.EDUSCENTRALIV

Procedure: Ultrasound Guided Central Line Placement

 

Indication/Medical Necessity: ***  (physicians can select more than one from drop down)

Need for central venous access after failure of peripheral access attempts

Need for central venous pressure evaluation

Need for pressors

Hypotension

Tachycardia

Sepsis

 

Location: ***(physicians can select one from drop down)

Right internal jugular

Left internal jugular

Right subclavian

Left subclavian

Right femoral

Left femoral

 

Procedure: Using the linear probe covered in a sterile sheath, a short axis of the vein was obtained.  This vein was completely compressible and was identified as separate from the adjacent non-compressible arterial structure.  Under dynamic guidance, the introducer needle was observed to tent the vein, and then to puncture it.

 

Overall Findings: (physicians can select one from drop down)

***Successful/Unsuccessful*** central venous catheterization under ultrasound guidance

 

Other comments: ***

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

.EDUSPARACENTESIS

Procedure: Ultrasound for paracentesis fluid localization

 

Indication/Medical necessity: *** physicians can select more than one from drop down)

 

Emergent drainage of ascites

Abdominal pain

Fever

Shortness of breath

Respiratory distress

 

Procedure: Using the low frequency probe, a suitable location for placement of the peritoneal catheter away from bowel and vascular structures was identified and marked.

 

Overall Findings: physicians can select one from drop down)

***Successful/Unsuccessful*** paracentesis was performed under ultrasound guidance.

 

Other comments: ***

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

.EDUSPERIPHERALIV

Procedure: Ultrasound for Peripheral IV Access

 

Indication/Medical Necessity: *** physicians can select more than one from drop down)

Patient requires placement of a peripheral venous catheter for emergent administration of IV fluids or medication.

Several blind peripheral attempts were unsuccessful

 

Location: *** physicians can select one from drop down)

Cephalic vein

Basilic vein

Deep brachial vein

Superficial brachial vein

 

Procedure:  Using the linear probe covered in a sterile sheath, a short axis of the vein was obtained.  This vein was completely compressible and was identified as separate from the adjacent non-compressible arterial structure.  Under dynamic guidance, the intravenous needle was observed to tent the vein, and then to puncture it.

 

Overall Findings: *** physicians can select one from drop down)

***Successful/Unsuccessful*** peripheral venous catheterization under ultrasound guidance.

 

Other comments: ***

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

.EDUSTHORACENTESIS

Procedure: Ultrasound for thoracentesis fluid localization

 

Indication/Medical necessity:*** physicians can select more than one from drop down)

Patient requires placement of a transthoracic catheter for emergent removal of pleural fluid

Shortness of breath

Chest pain

Respiratory distress

Hypoxia

Tachypnea

Dyspnea

 

Procedure: Using the linear probe covered in a sterile sheath, an area of fluid within the chest cavity was localized away from lung structures.

Under dynamic guidance, the introducer needle ***was/was not*** observed to enter the chest cavity into the pleural fluid. These images were recorded for archival purposes.

 

Overall Findings: physicians can select more than one from drop down)

***Successful/Unsuccessful*** thoracentesis under ultrasound guidance.

 

Other comments: ***

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

.EDUSPERICARDIOCENTESIS

Procedure: Ultrasound for Pericardiocentesis fluid localization

 

Indication/Medical necessity:*** physicians can select more than one from drop down)

Patient requires placement of a transthoracic catheter for emergent removal of pericardial fluid

Shortness of breath

Chest pain

Respiratory distress

Hypoxia

Hypotension

Tachycardia

Tachypnea

Dyspnea

Cardiac arrest

Chest trauma

Procedure: Using the low frequency probe, an area of fluid within the pericardial cavity was localized away from heart and lung structures. The introducer needle was observed to be in the pericardial sac within the pericardial fluid.

 

Overall Findings: physicians can select more than one from drop down)

***Successful/Unsuccessful*** pericardiocetesis under ultrasound guidance.

 

Other comments: ***

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

.EDUSARTHROCENTESIS

Procedure: Ultrasound for Joint Effusion fluid localization

 

Indication/Medical necessity:*** physicians can select more than one from drop down)

Patient requires emergent drainage of synovial joint fluid

Joint pain

Joint swelling

Inability to bear weight

Hypotension

Tachycardia

 

Location: ***

 

Procedure: Using the linear probe, an area of fluid within the synovial cavity was localized away from vascular structures.

 

Overall Findings: physicians can select one from drop down)

***Successful/Unsuccessful*** arthrocentesis under ultrasound guidance.

 

Other comments: ***

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

.EDUSLUMBARPUNCTURE

Procedure: Ultrasound for Lumbar puncture localization

 

Indication/Medical necessity:*** physicians can select more than one from drop down)

Unable to palpate landmarks for needle insertion

Prior unsuccessful attempts

Headache

Vomiting

Fever

Hypotension

Tachycardia

Altered mental status

 

Procedure: Using the linear probe, the middle lower back at the level of the 3rd, 4th and 5th lumbar disk spaces was evaluated to assess the best location for needle entry between the spinous processes.

 

Overall Findings: physicians can select one from drop down)

***Successful/Unsuccessful*** lumbar puncture under ultrasound guidance.

 

Other comments: ***

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

.EDUSSUPRAPUBICASPIRATION

Procedure: Ultrasound for suprapubic bladder fluid localization

 

Indication/Medical necessity:*** physicians can select more than one from drop down)

Patient requires placement of a suprapubic catheter for emergent removal of bladder fluid

Unable to pass a foley catheter through urethra

Abdominal pain, lower

Urinary retention

Hematuria

Hypotension

Tachycardia

 

Procedure: Using the low frequency probe, the lower abdomen was evaluated to assess the best location for needle entry area for fluid aspiration from the bladder away from vascular structures.

 

Overall Findings: physicians can select one from drop down)

***Successful/Unsuccessful*** suprapubic aspiration under ultrasound guidance.

 

Other comments: ***

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician

 

.EDUSNERVEBLOCK

Procedure: Ultrasound Guided Nerve Block

 

Indication/Medical necessity:*** physicians can select more than one from drop down)

Severe extremity pain

Right upper extremity fracture

Left upper extremity fracture

Right lower extremity fracture

Left lower extremity fracture

Multiple lacerations

 

Location: *** physicians can select one from drop down

Interscalene

Supraclavicular

Infraclavicular

Axillary

Femoral

Sciatic/popliteal

Complete Ankle block

Complete wrist block: radial, ulnar, median nerve

Partial wrist block: radial, ulnar, median nerve

 

Location: ***Right/Left***

 

Procedure: Using the linear probe, the short axis of the hyperechoic nerve in question was identified.  The location of the nerve was marked and identified separate from the adjacent vascular structures.  Under dynamic guidance, the introducer needle was observed in its longitudinal plane to go to the area of the nerve. Anesthetic was seen encircling the nerve.

 

Overall Findings: physicians can select one from drop down)

***Successful/Unsuccessful*** nerve block under ultrasound guidance.

 

Other comments: ***

Quality Assurance: *** These images were recorded for quality assurance, retrievability, and archival purposes.(this is a must for billing purposes)

Limitations/Complications of the procedure:***

Performed By: ***

Attending Physician Attestation: I was present and directly participated in the limited ultrasound procedure, have reviewed the imaging, and the above represents my personal interpretation as the attending physician