PoCUS exams should be appropriately documented in the patient chart, including the clinical indication, relevant ultrasound findings, and clinical interpretation. Detailed recommendations for clinical documentation and charting are provided in the PoCUS in Clinical Context: Indications, Limitations and Safety module.

 

Image Labeling

Appropriate labeling of saved ultrasound images is an important part of the examination workflow. Labels help identify the anatomy, orientation, laterality, and relevant findings shown in an image, making studies easier to interpret and review. Consistent labeling is particularly important when PoCUS exams are shared with or specifically reviewed by a specialist or consulting physician to support immediate patient care, as well as for quality assurance and learner feedback.

Saved images should include relevant labels, such as laterality (e.g., left/right), affected or unaffected side, and image orientation (e.g., transverse/longitudinal), as appropriate to the examination.

The exact labeling workflow may vary depending on the ultrasound machine being used. However, the following general steps apply to most systems.

 

1. Select the machine’s labeling function, for example, ABC, Text, or Annotate.

2. Position the cursor where you want the label to appear on the image

· Make sure the position is clearly visible and will not obscure any anatomy or relevant findings.

3. Add text to the image or clip

· Predefined image tags : Most ultrasound machines provide a selection of predefined image tags/labels for commonly used anatomical structures, orientations, and laterality. Select the appropriate tag from the available options.

· Manual text: If the desired tag is not available as a predefined option, select the keyboard or text entry function to enter a label manually.

4. Review annotations and then save the image/clip

5.  Remove labels using the machine’s delete or clear function (e.g., trash/garbage icon).

· Be sure to clear existing labels before switching between sides or views. This prevents an incorrect label from being carried over to the next image or clip.