Documentation

Our documentation recommendations are consistent with those from the Canadian Point of Care Ultrasound Society (CPoCUS). We share the belief that it is important for all physicians completing our modules to use consistent, unambiguous, and easily interpreted language when describing point of care ultrasound studies. It is important to chart using binary wording, and to limit the possible interpretations to those within our scope of practice. With this in mind, we endorse the following documentation recommendations from the Canadian Point of Care Ultrasound Society:

PoCUS for (insert indications here): negative/positive/indeterminate study: No/+ (insert pathology name here)

As an example, in a case of PoCUS for pneumothorax, in which a pneumothorax was found on the patient’s left side one would document the following in the chart:

PoCUS for PTX: positive: + L PTX

In addition to documenting your findings in the chart we strongly encourage users to record their images for QA review and to get ongoing feedback on your scans.