UPPER ABDOMEN US
The liver is normal in size with homogeneous echotexture.
Gallbladder wall thickness is normal; the lumen is anechoic.
The spleen is normal in size and echogenicity.
Both kidneys are normal in size; no stones.
Ultrasound checklist
The ultrasound report is often the fastest report written: the patient is on the couch, the next one is waiting, and someone else often types. That speed makes some errors systematic. Here are the most common ones, each with a practical safeguard.
1. Left and right mix-ups
In paired organs such as kidneys, ovaries, thyroid lobes, breast quadrants and testes, laterality errors are the most dangerous. "Right" said aloud can become "left" when typed, or a sentence left over from the previous patient can be signed unchanged.
Safeguard: say the side with every finding and keep right and left organs in separate sentences in the template. In Raporio's ultrasound mode, a code for one side changes only that side's sentence.
2. Size and unit errors
- mm and cm confused ("8 cm stone" slipping through).
- Only one dimension given; for nodules and masses at least two are more informative.
- No mention of the plane of measurement (long axis, AP diameter).
- No comparison with the previous size at follow-up.
Safeguard: write sizes in a fixed pattern ("15 x 12 mm") and fix the unit in the template sentence. In ultrasound mode the {size} placeholder expects only the number, so the unit is always right.
3. Unclear abbreviations
Abbreviations typed for speed can end up in the report unchanged and be meaningless or misleading for the clinician. The same abbreviation can mean different things in different units.
Safeguard: use abbreviations only for input and write them out in the report. In ultrasound mode the assistant types "gb stone 8" and the report shows a full sentence.
4. Contradictions left from the template
The most insidious error: a finding is added but the "normal" sentence for the same organ is not removed. The report can then say both "no gallstones" and "9 mm gallstone".
Safeguard: the finding must replace the normal sentence. Raporio puts the finding in place of the matching normal sentence and highlights the change.
5. Limitations not stated
Bowel gas, body habitus, fasting state or patient cooperation can prevent adequate assessment of some organs. Not saying so lets an unassessed organ pass as "normal".
The pancreatic tail could not be adequately assessed due to overlying bowel gas.
6. An impression that ignores the clinical question
For a patient referred with right lower quadrant pain, an impression that says nothing about the appendix leaves the clinician without an answer. Even "not visualised" is information. More in how to write a radiology report.
Frequently asked questions
What is the most dangerous ultrasound report error?
Laterality (left/right) errors, especially in paired organs, as they can directly affect treatment.
How many dimensions should be reported?
For nodules and masses, at least two; at follow-up, add the comparison with the previous size.
Should an organ that could not be assessed be mentioned?
Yes. Stating why (for example bowel gas) prevents it from being taken as normal.
Try it with your own template
Say your findings and Raporio fills in your template. Nothing to install, it runs in the browser.
