ABSTRACT
Documentation is the collation, synopsizing, and coding of printed material for future reference. It is also described as the act of supplying documents, supporting references, or records. Outside of the research realm, much of medical documentation is geared towards the medical record. Proper documentation of the medical record is required to ensure that all pertinent facts, findings, and observations regarding a patient are recorded in a chronologic fashion: past medical and surgical history, examinations, test results, treatments, and outcomes. Sound practice patterns must be established with regard to performance and documentation early in the development of this clinical tool. An often-neglected component in documentation is that of the equipment, and most particularly the general maintenance and routine cleaning and sterilization of the equipment used. Protocols are standards by which scanning and documentation of findings should be reported. Documented areas of interest must be imaged in a logical sequence to ensure proper and complete interpretation of the ultrasound examination.
