T/CNMIA 0044-2024 A practical general hospital ultrasound report template

Scope

Scope: This document is applicable to the ultrasound departments of comprehensive hospitals. For some specialized hospitals, there may be special clinical needs, and the professional requirements for ultrasound reports may be more specific. This ultrasound report template may not be fully applicable. This document provides ultrasound report templates for abdominal organs, superficial organs, blood vessels, gynecology, obstetrics, heart, and musculoskeletal systems; Main technical content: The quality of ultrasound medicine is the cornerstone of ensuring its important clinical value. In November 2018, the National Ultrasound Medical Quality Control Center published the "Expert Consensus on Quality Management Indicators for Ultrasound Medicine (2018 Edition)" [1]. Ultrasound examination operation guidelines and ultrasound diagnostic report guidelines are the two core contents of ultrasound medical quality control [2]. Therefore, the "Beijing Ultrasound Medical Quality Control and Improvement Center" Non-Public Group, the Ultrasound Professional Committee of the Beijing Non-Public Medical Institutions Association, and the Ultrasound Professional Committee of the China Non-Public Medical Institutions Association organized ultrasound experts to conduct a questionnaire survey on ultrasound report templates among ultrasound doctors nationwide. A total of 3,863 ultrasound doctors provided feedback, of whom 56.78% (2,139/3,867) reported that their departments' report templates contained terms such as "light spots" and "light masses", indicating the existence of non-standard report templates. 98.52% (3,806/3,863) of the doctors believed that their departments needed a set of standardized and efficient report templates. After repeated discussions, it was decided to establish an expert group to draft ultrasound report templates.

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