As sonographers we do wayyyyyyy more than take pretty pictures.
This is the process of how things work at my hospital.
The 1st thing that I do when I enter the ultrasound department is check the worklist.
The worklist consists of the patients name, identifying markers, the exam to be performed, the time of their appointment or their room number, depending on whether the patient is an inpatient or an outpatient, along with other patient information. Simply put, inpatients are individuals who have a room in the hospital and outpatients are patients that are coming in for an appointment.
The next step is to obtain the patients paperwork and to look up the patients history. Getting the patients history is one of the most important steps. This allows you to have an idea of what you are to expect with a particular patient. Referring to the history also informs the Sonographer of any pathology that was identified in the previous exam that they should try to obtain images of in the new study. When reviewing relevant history, I personally place little notes on the back of the patient paperwork as a little reminder of the locations of interest and the measurements of previous pathology (this can be useful later on when preparing the worksheet).
After reviewing the patients history, it’s now time to get a worksheet for the patient. The process of getting worksheets may vary depending on your department. In my department we have a program on the computer that allows us to enter the patients name and MR number (a number assigned to the patient by the hospital) and the exam that the patient is going to have performed. This process ensures that the correct patients information is on the correct worksheet for the exam to be performed.
OUTPATIENT
Once the patients paperwork is prepared, if you have an Outpatient it is now time to collect their prescription. The prescription is pretty much permission from the doctor saying that they want a particular exam to be performed on their patient. It is imperative that the exam requested on the prescription is the same exam that is listed on the paperwork of the patient. If not, this has to be corrected before any exam can be performed on that patient. Once that is done now is a good time to “Start” the exam to the machine you will be using.
Now it’s time to get the patient from the waiting room 😊YAY. Once you call the patient in from the waiting room it is absolutely necessary and extremely vital to check the identifying markers on the patients wristband and make sure that they are identical to the markers on your worksheet. The identifying markers usually include the patients birthday and 2 other numbers assigned to the patient by the hospital. If the numbers are not identical you CAN NOT perform an exam on the patient until this is fixed. If you were to perform the exam, it would be as if you performed the exam on the wrong patient. No Bueno!
Seeing that we now have the correct patient and that all the identifying markers match, we can proceed with taking the patient into the room and performing the desired exam. After finishing the exam and walking the patient out, it is now time to write up the worksheet and mention any pathology that was visualized during the exam. Depending on your Radiologists, now could also be a good time to speak with them about any questionable pathology and see if they feel certain details on your worksheet should be mentioned or omitted.
Next it is time to review your images and write up your worksheet. When doing this make sure to document the pathology you visualized and even draw a picture if you find it would be helpful to the Radiologist. Once you have completed filling out your worksheet, you can now sign it and scan it into the computer system. After checking the images again, and ensuring that your worksheet is now seen along with the images of your exam, you can now “End” the exam on the system so that it can be visible to the Radiologist to be read and dictated.
INPATIENT
The process for inpatients is pretty much the same for outpatients except that for inpatients you have to go “portable”. Going portable pretty much means that you will be taking a portable machine and going to the patients room to perform the exam that the doctors requested. When going portable make sure to carry extra towels and nice warm gel for the patients. You never know what you will encounter when going portable so be sure to carry extra supplies, just in case.
As I mentioned earlier, this is how things are done at my hospital. Every facility is different though so don’t be surprised if your location doesn’t do things exactly as I listed them here.
Hope you found this informative and helpful.
Happy scanning
Catch you in the next blog
Stephanie
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