Obstetrical Ultrasound Report Second and Third Trimester
Obstetrical Ultrasound Report Second and Third Trimester (without Biophysical Profile)
Method of Rodney WM, modified from Hahn RG, Deutchman ME
Updated 11-4-07 Procedural Skills and Office Technology ()
Patient Information-HIGH RISK V23.89 REQUIRES DOCUMENTATION AND SOME IMAGES
|Name: Age: G: P: Ab: Medical Record #: |
|Today’s Date: ___/___/____ LMP:____________ Certain:_____ Uncertain:_____ Unknown:_____ |
|This is: (circle one) Initial Exam _____ Repeat _____ [Date of first US exam: ___/___/____ ] |
|EDD is:____________ based upon (circle one) LMP Ultrasound FUNDAL HEIGHT___________ |
Indication for this exam: (check one) Large for dates:____ 656.63 Uncertain Dates:____ V28.4 Small for dates:____ 656.53 Vaginal bleed: ____ 641.93 Abdominal pain:____ 789.00 Breech presentation:__652.23; Fetal anomaly ?-655.93
Fetal distress: ____656.33 Oligohydraminos:___658.03 Late Prenatal Care ___V23.7
Sp Ab w/hemorrhage:____634.10 Threatened abortion: ____640.03 Other: GDM, PIH, 40-42 wks, trauma, preE
-----------------------
Fetal Survey
Number: _____
Presentation: Cephalic: ( Breech: ( Other: (
Anatomy:
Seen Not Seen
Head/symmetrical contents ( (
Cardiac motion/four chambers ( (
Spine (long and trans) ( (
Stomach ( (
Bladder ( (
Renal region ( (
Abdominal wall ( (
Fetal abnormality: Seen ( Suspected ( Not Seen (
(Describe in Comments Section if seen)
Placenta
Location: Anterior ( Posterior (
R Lateral ( L Lateral (
Height: Fundal ( High (
Mid ( Low (
Previa? (circle one choice)
None Marginal/Partial Complete
Grade of Placenta: (0,1,2 or 3) ________
Amniotic Fluid Amount:
Normal ( Decreased ( Increased (
Amniotic fluid index ________cm (optional)
Uterine Pathology: Seen ( Not Seen (
Describe:___________________________________
Fetal Biometry
Measurement (cm) Age (wks)
BPD ________________ _________
OFD ________________ Ratios: BPD/OFD _____ (nl .70-.88)
HC ________________ _________ FL/AC _____ (nl .22 + .2) (only valid at
FL ________________ _________ >24 wks)
Abdomen AP ________________ HC/AC _____ (see reference tables,
Abdomen T ________________ ratios vary with age)
AC ________________ _________ Fetal weight estimate:_________gm (_______%ile)
Composite gestational age:
If previous scan was done, is the interval growth normal? YES ( NO ( N/A (
Conclusions
Yes No “BEST” EDD is: ____/____/____
1. Was fetal survey satisfactory for age? ( ( Comments:__________________________________
2. Is a change in the EDD recommended? ( ( ____________________________________________
3. Is consultation recommended? ( ( ____________________________________________
4. The possibility of non-visualized fetal
anomalies explained to the patient? ( (
______________________________________ ___________________________________ _____________________
Sonographer Physician Signature Date
+ _______wks
................
................
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