Ultrasound-guided procedure report template
A structured ultrasound-guided procedure report template used for ultrasound-guided aspiration, fine-needle aspiration, core biopsy, pleural or ascitic drainage, abscess drainage, other centre-approved guided procedure. It covers 4 sections and 19 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
Ultrasound-guided procedure under aseptic technique.
What to include: sections and measurements
Consent
- Informed consent: written consent obtained · verbal consent obtained · not obtained (explain)
- Consent given by
- Consent note
Procedure
- Procedure: aspiration · fine-needle aspiration · core biopsy · pleural drainage · ascitic drainage · abscess drainage …
- Site
- Laterality: right · left · midline / n/a
- Operator
- Assistant
- Needle / catheter
- Local anaesthesia
- Number of passes
- Volume aspirated / drained (mL)
- Technique
Specimen repeatable
- Specimen type
- Container / fixative
- Sent to
Complications and aftercare
- Immediate complications: none observed · present (describe)
- Complication details
- Aftercare instructions
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.