First Trimester Ultrasound Report
Medicos’ First Trimester Ultrasound Report
Procedural skills and Office Technology Project ()
Updated 11-4-07[wmr]
BACKGROUND (History):
Name:_____________________________ Date:___________________Medical Record #:___________
DOB:__________________ Physician:__________________________________
Race: ____Black ____Cauc ____Hispanic ____Asian ____Other:_______________
Weight: _________pounds G____ P____ AB____ Clin EGA ______weeks
LMP: ______/______/______ Certain ____ Uncertain ____ Unknown ____
EXAM DATE: ______/______/______ INITIAL ____ REPEAT ____
Indications for this scan: (check one)
Abdominal pain 789.00 Large for dates 656.63 Menstrual disorder 626.9 Ovarian cyst 620.2
Pelvic pain 625.93 Sp Ab with hemorrhage 634.10 Sp Ab no complication 634.90
Threatened abortion 640.03 Fetal movements decreased 655.70 Late prenatal care V23.7
Vaginal Bleeding 623..83 Threatened Preterm Delivery 644.2 Threatened Ab 640.03 Fetal anomaly suspected 655.93
RESULTS:
Pregnancy Location: ……………..Intrauterine____ Ectopic ____ Uncertain ____
Fetal Number:_________ Gestational Sac Number:_____
| |Seen |Not Seen |
|Cardiac Activity | | |
|Body Activity | | |
|Pelvic Mass | | |
-----------------------
Gestational Sac:
________cm x _________cm x _________cm
Mean Sac Diameter: __________cm
CRL:=_________mm; EGA=_________
ULTRASOUND GESTATIONAL AGE: __________wks
EDD BASED ON LMP: ______/______/______ EDD BASED ON THIS ULTASOUND: ______/______/______
Based on these data, the chosen EDD is:____________________________________________________
Remarks:_____________________________________________________________________________
_____________________________________________________________________________________
Sonographer:_________________________ Supervising Physician:____________________________
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