Documenting your findings on point of care ultrasound is important for at least two reasons. First, obviously, if you see an ectopic pregnancy, you should write that in the chart just like you should document a heart murmur if you hear one. Second, is that point of care ultrasound is a billable procedure. There are, however, some stipulations that must be met to ensure that the studies are truly indicated and interpreted at an appropriate level if your hospital wants to bill for them. Some of the stipulations relate to the documentation.

Specifically, to bill for a point of care ultrasound, the following must be obtained:

1. Permanently recorded images, which must be available for review
2. An order for the study
3. The indication of medical necessity
4. A written report
5. An interpretation
6. A physician’s signature

To that end, your facility can decide how to meet these requirements. The following videos show how to place an order for a point of care ultrasound, how to archive the images, and how to document a point of care ultrasound at our institution. (This is a process that is always being improved upon. It is generally accurate as of this writing, but these processes change every once in a while.)

How to order a point of care ultrasound

How to archive a point of care ultrasound

How to document a point of care ultrasound