FIBROSCAN REPORTING FORM - UTHSCSA

PATIENT INFORMATION MEDICAL RECORD NUMBER

PATIENT NAME Last

FIBROSCAN REPORTING FORM

CLINIC NAME First

TODAY'S DATE (mm/dd/yyyy)

M.I.

DATE OF BIRTH (mm/dd/yyyy)

FIBROSCAN EXAMINATION INFORMATION

A series of at least 10 Vibration Controlled Transient Elastography (VCTETM) measurements was performed by placing the probe _ _ (M, XL) over the center of the liver parenchyma and mechanically inducing a 50 Hertz shear wave. Each resulting VCTETM measurement was analyzed to determine shear wave propagation speed and calculate the equivalent liver stiffness. All measurements were reviewed by the operator and physician for technical accuracy. Data variability across the acquired measurements was quantified with IQR/Median percentage. The median liver stiffness was _ __ kPa with IQR/Median percentage of __ ___.

The measure CAP ultrasound attenuation rate value was _ __dB/m.

_________

_ (print physician name) assessed the FibroScan examination

results by taking into account the quality of the measurement thumbnails, number of measurements, and

IQR/Median ratio.

*Other medical data documented in corresponding FIBROSCAN CLINICAL FORM.

REPORTING PHYSICIAN

NAME Last

First

POSITION

Page 1 of 1

SIGNATURE ORGANIZATION

Version 2: 10/19/2018

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