Sonografie Befund Experte-ultrasound report generation tool

Example

In a sonographic examination of the abdomen, the tool prompts the user to provide a detailed report, including the size and appearance of organs such as the liver, spleen, kidneys, etc. Each section is labeled clearly (e.g., 'Liver', 'Spleen') with a bullet-point format for easy reference.

Scenario

A radiologist uses Sonografie Befund Experte to document findings in an abdominal ultrasound. The tool ensures that all relevant organs are assessed and described systematically, ensuring no details are overlooked.

Example

The tool encourages a thorough evaluation of each organ system, summarizing findings under a 'Beurteilung' (Assessment) section. For example, in the case of a thyroid ultrasound, the report includes the presence of nodules, echogenicity, and the volume of each thyroid lobe.

Scenario

A sonographer performs a thyroid ultrasound and uses Sonografie Befund Experte to record the findings. The detailed template helps in identifying and documenting any abnormalities such as nodules or changes in echotexture, providing a complete overview for further clinical evaluation.

Example

After summarizing the sonographic findings, the tool guides the user to select an appropriate ICD-10-GM code that corresponds to the clinical findings. For instance, in the case of unspecific abdominal pain, the code R10.4 is suggested.

Scenario

During the reporting process, a radiologist uses Sonografie Befund Experte to align the sonographic findings with a diagnostic code. This standardization helps in accurate medical record-keeping and supports billing processes in healthcare settings.