How to write an ultrasound report
A practical guide for SonoTez users, compiled from published reporting standards (sources at the end). It describes good practice; it does not replace your centre's clinical policies. Thresholds quoted in template help texts are reference notes only. SonoTez never applies them automatically.
1. Report structure
Every report should contain these parts, in this order (ACR Practice Parameter for Communication of Diagnostic Imaging Findings, 2025; RCR Standards for interpretation and reporting, 3rd ed. 2025):
| Part | What to write | Where in SonoTez |
|---|---|---|
| Identifiers | Patient name, age/DOB, sex, MR number, exam name, date and time, referring clinician (or "self-referred") | Filled automatically from registration |
| Clinical indication | The clinical question being asked | Indication field at reception / workspace |
| Comparison | Relevant previous studies, or "No previous imaging was available for comparison" (cmp) | Narrative / phrase |
| Technique | Approach (transabdominal, transvaginal, transfontanelle), transducer, Doppler, contrast | Template default technique (editable) |
| Limitations | Anything that reduced sensitivity: bowel gas, body habitus, non-fasting, underfilled bladder, pain | Structure state Limited plus limitation phrases (gas, nfs, bmi, ubu, pain) |
| Findings | Organ by organ in examination order, with measurements, units, plane and side | Structured sections |
| Impression | Answers the clinical question, then other findings in order of importance | Impression block |
| Recommendations | Specific, actionable, with an interval if follow-up is needed | Recommendation block |
| Signature | Reporting doctor's name, qualification and PMDC number | Doctor profile, printed on finalization |
2. Findings versus impression
- Answer the question first. If the referral asks "?appendicitis", the impression starts with the answer: "No sonographic evidence of appendicitis", or "Appendix not visualized; no secondary signs".
- Rank by importance. Number the items when there is more than one.
- Nothing new in the impression. Every item in the impression must be described in the findings.
- Do not repeat measurements in the impression unless they drive management.
- Be specific when you can. Give a differential only when it is genuinely uncertain. Use graded certainty words consistently (Panicek & Hricak, AJR 2016):
- consistent with: very likely (> 90%)
- suspicious for / probably: about 75%
- possibly: about 50%
- less likely: about 25%
- unlikely: < 10%
- Separate normal variants from pathology.
3. Wording
| Avoid | Prefer | Why |
|---|---|---|
| "Absent" for a structure you did not see | "Not visualized" (state Not visualized) | "Absent" claims it is not there. SonoTez never turns Not visualized into "normal". |
| "Normal" for a partly seen organ | Mark it Limited and say what was not seen | A normal sentence is suppressed for limited structures |
| Reflex "Clinical correlation advised" | Say what correlation is needed, e.g. "correlate with serum lipase" | Vague advice adds nothing |
| "X cannot be excluded" | Say what would exclude it, e.g. "MRI if clinically suspected" (msknd) | Turns hedging into an action |
| "Within normal limits" without a reference | A measurement, or "normal" | A limit implies a named reference |
| Free-typed side | The structured Right/Left fields | Prevents laterality errors |
| Unexplained abbreviations and eponyms | Plain words | The report is read by clinicians and patients |
Use standard lexicons where they exist: BI-RADS, TI-RADS and O-RADS descriptors in the breast, thyroid and pelvis templates. SonoTez records the descriptors. The doctor writes any category in the impression.
4. Limitations
State them whenever they reduce sensitivity (ACR 2025). Example phrases are installed as shortcuts:
gas: Overlying bowel gas limited assessment.nfs: The patient was not fasting, which limits gallbladder assessment.bmi: Body habitus reduced image penetration and resolution; small lesions may not be detected.ubu: The urinary bladder was underfilled; pelvic organs were suboptimally assessed.pain: Patient discomfort and limited cooperation restricted the examination.
5. Urgent and unexpected findings
The ACR (2025) requires non-routine communication for:
- findings that need immediate or urgent intervention;
- findings that differ from a previous interpretation where failure to act may harm the patient;
- significant unexpected findings that could worsen if not acted on.
How to communicate:
- Speak to the clinician: by telephone or in person, to the referring clinician or their designee. Electronic messages count only with documented receipt.
- Self-referred patients: the reporting doctor is responsible for making sure the patient is informed. This is common in walk-in practice.
- Record it in the report: who was told, when and how (
call: "These findings were discussed by telephone with Dr ___ at __:__ on __/__/____"). - Log it in SonoTez: use the Critical findings log. An SMS or WhatsApp delivery receipt is not an acknowledgment.
Typical urgency (ACR Actionable Reporting Work Group, Larson JACR 2014):
| Urgency | Examples |
|---|---|
| Within minutes | Ruptured ectopic pregnancy, testicular or ovarian torsion, ileocolic intussusception, strangulated hernia, acute limb ischaemia, new ICA occlusion or near occlusion |
| Within hours | Appendicitis, abscess, acute DVT, pyloric stenosis, portal or hepatic vein thrombosis, large effusion with mediastinal shift |
| Within days | Suspicious incidental mass, suspicious lymph nodes |
6. Images
- Store permanent images. Label each with patient ID, date, side and plane.
- Normal studies: keep a representative image of each organ examined.
- Abnormalities: image each one in two planes, with and without callipers.
- Doppler: store spectra with the angle correction visible. Use cine clips for dynamic findings.
- Keep images for the legally required retention period.
7. Exam-specific notes (new templates)
| Template | Key points |
|---|---|
| Carotid and vertebral Doppler | Grade ICA stenosis as a NASCET-based range (SRU 2003). Always state vertebral flow direction. Calcified plaque limits grading. Contralateral occlusion raises velocities. |
| Lower-limb arterial Doppler | Report the worst lesion per limb (segment, PSV ratio, length), inflow versus outflow, run-off and ABI. A dampened CFA waveform implies inflow disease. |
| Upper-limb arterial Doppler | Subclavian to palmar arch. Record both brachial pressures: an inter-arm difference > 15 mmHg suggests proximal stenosis. Record provocative arm positions for thoracic outlet studies. |
| Liver shear-wave elastography | Record the system, method and units: results are vendor-specific and not interchangeable with FibroScan. Use the median of valid measurements with IQR/median (≤ 30% kPa, ≤ 15% m/s). Interpret with the SRU 2020 'rule of four' for the known aetiology and list confounders (inflammation, cholestasis, congestion, food). |
| Transrectal ultrasound (TRUS) | Give the volume and the entered PSA; the doctor may write PSA density. Describe lesions by side, level and zone. A normal TRUS does not exclude cancer; MRI with PI-RADS is the reference for lesion detection. |
| Renal artery Doppler | Report kidney length (required). State whether each main renal artery was seen from origin to hilum: if the origin was not seen, the study is indeterminate, not negative. |
| Hepatic and portal Doppler | Record fasting state. Report portal vein patency and direction, signs of portal hypertension and hepatic vein patency. Pulsatile portal flow points to the heart. |
| Shoulder | Measure tears as ACR describes (surface, depth, width, retraction, distance from biceps). Impingement has limited validity on ultrasound. |
| Knee | Ultrasound does not exclude meniscal or cruciate tears. Say so. A ruptured Baker cyst mimics DVT. |
| Ankle and foot | Report the Achilles tear gap in plantarflexion. Measure the plantar fascia at the calcaneal origin and compare sides. |
| Chest and pleura | Effusion side, character (Yang categories), depth. Mark the site in the procedure position. |
| Hernia | Scan at rest and on Valsalva. Relate groin hernias to the inferior epigastric vessels. Fluid in the sac, a thickened bowel wall or absent flow is urgent. |
| Neck nodes | Report by level, short axis and morphology. Morphology outweighs size. Necrosis is abnormal at any size. |
| Salivary glands | Duct dilatation and calculi must be reported. Describe focal lesions in three dimensions. |
| Neonatal cranial | Record corrected GA and day of life. Grade haemorrhage per side (Papile, or Volpe for PVHI). Track ventricular index serially. |
| Infant hip (Graf) | Use only a standard plane. Record alpha, beta, coverage and stability. The doctor selects the Graf type. |
| Pylorus | Muscle thickness, channel length and observed gastric emptying. Pylorospasm mimics stenosis. |
| Intussusception | Survey all four quadrants and the whole colon. Ileocolic intussusception is urgent. Transient small-bowel intussusception usually needs only a repeat scan. |
| Appendix | Follow the appendix to its tip. If not visualized, record secondary signs (appnv), never "normal". |
Sources
- ACR Practice Parameter for Communication of Diagnostic Imaging Findings (rev. 2025): https://gravitas.acr.org/PPTS/GetDocumentView?docId=74
- RCR, Standards for interpretation and reporting of imaging investigations, 3rd ed. (2025)
- SoR & BMUS, Guidelines for Professional Ultrasound Practice, 8th ed. (2023)
- ACR–AIUM–SPR–SRU practice parameters: extracranial cerebrovascular (2026), peripheral arterial (2025), native renal vessels (2023), abdomen/retroperitoneum (2026), musculoskeletal (2022), thyroid and extracranial head and neck (2022), neonatal neurosonography (2020), developmental dysplasia of the hip
- Grant EG et al. Carotid artery stenosis: SRU consensus. Radiology 2003;229:340–346
- Cossman DV et al. J Vasc Surg 1989;10:522 (arterial PSV ratio); AHA/ACC lower-extremity PAD guideline 2016 (ABI)
- Hoffmann U et al. 1991 (renal–aortic ratio); McNaughton DA, Abu-Yousef MM. RadioGraphics 2011;31:161–188 (liver Doppler)
- Barr RG et al. Update to the SRU liver elastography consensus statement. Radiology 2020;296:263–274; EFSUMB liver elastography guidelines (2017 update)
- BTS Clinical Statement on Pleural Procedures, Thorax 2023; Volpicelli G et al. Intensive Care Med 2012 (lung ultrasound)
- Rettenbacher T et al. AJR 2001;177:1061 (hernia incarceration); Muysoms F et al. Hernia 2009 (EHS classification)
- Leenhardt L et al. ETA guidelines, Eur Thyroid J 2013;2:147; Ahuja AT et al. Cancer Imaging 2008 (neck nodes)
- Papile LA et al. 1978; de Vries LS et al. 1992; Graf R 1980; Levene MI 1981
- Panicek DM, Hricak H. AJR 2016 (certainty lexicon); Larson PA et al. JACR 2014 (actionable findings)
Several thresholds in the help texts come from the literature as summarized during research and still need to be checked against the primary papers. The clinical lead must verify every number before approving a template (see [CLINICAL_SAFETY.md](CLINICAL_SAFETY.md)).