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Save and label the images. A medical record is not complete with just a written description of an image, whether that is a radiograph, an ultrasound image, computed tomography (CT), or magnetic resonance imaging (MRI). The image must be there to back up the interpretation. Furthermore, the other imaging modalities contain information to indicate exactly where an image was obtained. For example, the radiograph has anatomical landmarks and for both CT and MRI, there is a pilot image that records where all the remaining images are obtained. For ultrasound images, there may not be any definitive markers.

An ultrasound image that makes sense to the sonographer when it was recorded may make no sense when under review two days or even two hours later. One of the most common mistakes sonographers make is not labeling their images. Label the organ or structure of interest and label your orientation as longitudinal versus transverse, if it is not evident from the image. There will be times when there are no anatomical landmarks evident on the image and labeling is your only guide (Figure 4.12).

Most ultrasound machines have some sort of body pattern that can be placed on the image with an icon to show the approximate location of the probe (see Chapter 2). Put all labels outside the image, too. Placing words across the image can potentially hide diagnostic information. If you must write across the ultrasound image, first save a picture of the unadulterated image and then save a second picture of the annotated image. Short (3–10 second) video clips can also be saved on most ultrasound machines.

For recording ultrasound findings in medical records, see suggested goal‐directed templates in the respective chapters throughout the textbook.

Figure 4.12. Labeling the image. The same image in (A) and (B) of a liver mass. The location cannot be determined by the image itself and thus the use of the body icon helps point out where the image was taken. The mass itself is circled using the various measurement features of the ultrasound machine. The measurements of the mass are displayed in the upper right of image (B). Source: Courtesy of Robert M. Fulton, DVM, Richmond, VA.