Detailed fetal anomaly examination report template
A structured detailed fetal anomaly examination report template used for detailed fetal anomaly examination, fetal echocardiography. It covers 8 sections and 55 fields.
Demonstration content. Review and approve this template with your clinical lead before clinical use. Reference values shown in SonoTez are notes only and are never applied automatically.
Technique
Transabdominal obstetric ultrasound.
What to include: sections and measurements
Gestation
- Number of fetuses: singleton · twin · triplet · higher order
- Chorionicity / amnionicity (as documented)
Fetus repeatable
- Cardiac activity: present · absent · not yet assessable
- Fetal heart rate (entered) (bpm)
- Lie: longitudinal · transverse · oblique · unstable
- Presentation: cephalic · breech · transverse · oblique · variable
- Fetal movements: present · not seen during the scan
Biometry
- BPD (mm)
- HC (mm)
- AC (mm)
- FL (mm)
- EFW (g) calculated
- BPD - GA as reported
- HC - GA as reported
- AC - GA as reported
- FL - GA as reported
- Average GA as reported (with reference)
- EDD by this scan (as reported)
Placenta
- Location: anterior · posterior · fundal · lateral
- Segment: upper segment · lower segment
- Relation to internal os: clear of the os (no previa) · low-lying · covering the os
- Distance from internal os (mm)
- Maturity grade (doctor-assessed): grade 0 · grade i · grade ii · grade iii
- Other placental findings
Amniotic fluid
- Method: single deepest pocket · amniotic fluid index · subjective assessment
- Measurement (cm)
- Doctor's assessment: appears normal · appears reduced · appears increased
Anatomy checklist
- Skull and brain: assessed - appears normal · limited view · not seen · abnormal
- Skull and brain - note
- Face and lips: assessed - appears normal · limited view · not seen · abnormal
- Face and lips - note
- Spine: assessed - appears normal · limited view · not seen · abnormal
- Spine - note
- Heart (four-chamber and outflow views): assessed - appears normal · limited view · not seen · abnormal
- Heart (four-chamber and outflow views) - note
- Thorax: assessed - appears normal · limited view · not seen · abnormal
- Thorax - note
- Abdominal wall and cord insertion: assessed - appears normal · limited view · not seen · abnormal
- Abdominal wall and cord insertion - note
- Stomach: assessed - appears normal · limited view · not seen · abnormal
- Stomach - note
- Kidneys: assessed - appears normal · limited view · not seen · abnormal
- Kidneys - note
- Bladder: assessed - appears normal · limited view · not seen · abnormal
- Bladder - note
- Upper limbs: assessed - appears normal · limited view · not seen · abnormal
- Upper limbs - note
- Lower limbs: assessed - appears normal · limited view · not seen · abnormal
- Lower limbs - note
- Umbilical cord vessels: assessed - appears normal · limited view · not seen · abnormal
- Umbilical cord vessels - note
Cervix
- Approach: transabdominal · transvaginal · transperineal
- Cervical length (mm)
- Internal os: closed · funnelling · open
Other findings
- Other findings
Writing the impression
Answer the clinical question first, list the remaining findings in order of importance, and keep anything new out of the impression. If a structure was not fully seen, say so and give the reason. See how to write an ultrasound report for wording and certainty terms.