Ultrasound Protocol for Abdominal Organs: Template for Description and Conclusion for Physicians
Documentation Basis
According to the AIUM Practice Parameter for Documentation of an Ultrasound Examination (2025 Revision), the protocol must contain identifying data and the body of the report with a description of the study. Mandatory fields are presented below.
Mandatory Administrative Fields
| Field | Source |
|---|---|
| Ordering provider's name | AIUM, 2025 |
| Location of the ultrasound facility and contact details | AIUM, 2025 |
| Relevant clinical information: indication for the study and/or current ICD code | AIUM, 2025 |
| Date and time of the study | AIUM, 2025 |
| Specific ultrasound study performed | AIUM, 2025 |
| Indication of method when using endocavitary techniques | AIUM, 2025 |
Identification (EFSUMB, 2022)
According to the EFSUMB Position Paper (2022), the mandatory content of the report includes: 1) identification of the institution (name of the hospital/practice, referring physician, and investigator); 2) patient identification (last name, first name, gender, date of birth; in a hospital setting, the address may be replaced by an internal chart number).
Body of the Report
According to AIUM (2025), the body of the report should contain a description of the study, including: description of the studies and/or procedures performed; comments on the components of the examination according to the relevant standard(s).
Written Request for Study
ACR-AIUM-SPR-SRU (2023) requires that a written or electronic request for an ultrasound of the abdomen and/or retroperitoneal space contains sufficient information to justify medical necessity and correct performance and interpretation. Justification includes: 1) signs and symptoms and/or 2) relevant history (including known diagnoses).
Report Formats
According to EFSUMB (2022), conventional reports are written in expanded sentences with fixed formulations for normal and pathological findings. Structured reports with digital 'templates' standardize and simplify documentation, sometimes replacing sentences with short phrases.
Conclusion Formulations
Specific threshold values and normative criteria for abdominal organs in the provided fragments are not included — [clarify] according to the relevant standard ACR-AIUM-SPR-SRU (2023).
Frequently asked questions
What fields are mandatory in the ultrasound protocol?
According to AIUM (2025): ordering provider, location and contacts of the institution, clinical information/indication or ICD code, date and time, specific study, and indication of method for endocavitary techniques.
What should a written request for an abdominal ultrasound contain?
According to ACR-AIUM-SPR-SRU (2023) — information justifying medical necessity: signs and symptoms and/or relevant history, including known diagnoses.
How does a structured report differ from a conventional one?
According to EFSUMB (2022), a conventional report consists of expanded sentences with fixed formulations; a structured report uses digital templates and short phrases, standardizing the document.
What patient data is mandatory?
According to EFSUMB (2022): last name, first name, gender, date of birth; in a hospital setting, the address may be replaced by an internal chart number.
Are there normative size standards for organs in the sources?
The provided fragments do not include specific thresholds and norms for abdominal organs — clarification is required according to the relevant standard [clarify].