Recommended Information For Reports From
Routine Screening Ultrasound at 16-20 Weeks Gestation
(Data elements reflect singleton gestations only)
1.
Facility name:
2.
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General and Patient Demographic Information
Patient name
Second patient identifier
Age or date of birth
Date of LMP
 Examination(s) requested
3.
Number of fetuses
4.
Fetal Measurements
 Biparietal Diameter (BPD) - millimeters and weeks
 Head circumference – millimeters and weeks
 Abdominal circumference – millimeters and weeks
 Femur length – millimeters and weeks
 Calculations of:
1. Gestational age by examination (including range of variation – weeks)
2. Gestational age by LMP
3. Gestational age by previous sonograms
 Interpretation:
5.
Fetal Anatomy (reported as “normal”, “abnormal”, or “not seen” with explanations). The sonologist may choose to list
all anatomy scanned but should consult the recommended list below. 1
6.
Maternal Anatomy (reported as “normal”, “abnormal” or “not seen” with explanations)
 Uterus
 Cervix
 Adnexa
7.
Amniotic Fluid
 Volume from measurement of the deepest pocket or with reference to the amniotic fluid index (optional).
(reported as “normal”, “oligohydramnios” or “polyhydramnios”)
8.
Placenta Position such as:
 “Normal” or “>2 cm from internal os”
 “Low” or “< 2 cm from internal os”
 “Previa” or “covering the internal os”
 “Indeterminate” or “imprecise relation between the edge of the placenta and the internal os”
9.
Interpretations should also include:
 A summary of findings sufficient to address the reason/indication for the study
 Advice regarding the need and time frame for follow-up studies
 Advice regarding referral for further assessment when warranted
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Reason/Indication for request (ie: routine/screening)
Requesting physician
Date of examination
Interpreting radiologist
Date of dictation or transcription
1
The following anatomy should be scanned, recorded and interpreted when possible at a routine screening study at 16 to 20
weeks gestational age: *head shape, *ventricles, *posterior fossa, *face, *spine, *diaphragm, *4-chamber heart, *heart
axis, *cardiac outflow tract, *stomach, *kidneys, *bladder, *cord insertion, *3-vessel cord, *arms, *hands *legs, *feet
CPSA: September 2002
Replaces: June 2000