# MD does OB US



## Lisa Bledsoe (Oct 22, 2010)

I know there must be something out there detailing what must be included in the documentation performed by the physician in the office.  If anyone has any links I would be very grateful!


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## Lisa Bledsoe (Oct 26, 2010)

*Anyone?*

I have the opportunity to educate a new physician (to our practice) on the correct documentation but I need some resources...and then maybe I can get the "older" docs to do it the right way too...


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## preserene (Oct 26, 2010)

Lisa , please Check if this could be useful;Guidelines for Performing Ultrasound Examinations in the Pregnancy:
by Sanctity of Human Life Dept

Editor's note:
If a center follows these general standards as keys to medical excellence, including the roles of a medical director, a nurse manager, the ultrasound, nurses and the physician/sonographer in ultrasound, then it will be offering patients quality care. 
Clinical practice guidelines are common within the medical field, with over 1,500 issued in the past decade. 
Within the medical arm of the pregnancy center movement, there has been an increasing awareness of the need to give some guidance and standards to those performing ultrasound examinations at their centers.
The Physicians Resource Council of Focus on the Family has assisted in drafting, reviewing, and approving these evolving standards. The authors agree that if a center follows these guidelines, they will be giving care within the medical scope of practice for pregnancy centers doing ultrasound exams and providing other limited medical services. 
Definition of Abortion-Minded and Vulnerable 

General Standards 
•	The clinic will operate under the supervision of a physician serving as the medical director. If the medical director does not have obstetrical experience, the clinic will have a local physician with obstetrical training available for consultation.
•	The medical clinic should strive to have trained medical personnel on site whenever the clinic is open. At those times when a physician or a nurse is not on site, one will be available by phone for consultation.
•	A nurse manager who reports to the medical director will supervise the medical operations of the clinic.
•	Services will be provided for abortion-minded and abortion-vulnerable women to help them in the decision-making phase of their pregnancy. The provision of ultrasound services to women who are not abortion-minded or abortion-vulnerable is at the discretion of the medical director. 
Ultrasound examinations are a medical procedure requiring a physician's order, supervision, and review.
Ultrasounds will be performed only for appropriate medical indications by certified, medically appropriate staff.
LPNs and x-ray technicians may be allowed to perform limited ultrasound scans depending on the scope of practice in the state.
•	The medical clinic will adhere to all applicable licensing requirements.
1.	All physicians, nurses, sonographers, or x-ray technicians will hold current state-appropriate licensure, certification, and/or registration.
2.	The clinic will acquire any necessary state licensure.
3.	The clinic will acquire a CLIA waived test status to do pregnancy tests in states that consider this necessary.
•	The clinic will obtain and maintain medical malpractice insurance.
•	The clinic will adhere to the standards set for medical clinics by OSHA.
•	The clinic should follow the guidelines for obstetrical ultrasound set forth by one of the nationally recognized organizations in the field: ACOG, AIUM, or AWHONN.
The clinic should not perform ultrasound examinations of clients unless it has an established obstetrical referral mechanism.
•	The clinic will establish and follow a Policy and Procedures Manual. It will be reviewed and updated regularly.
Keys to Medical Excellence 
•	Role of the medical director
1.	Must possess a current license to practice medicine and function in accordance with the state's Board of Medical Examiners.
2.	Agrees with the center's Statement of Faith, Mission Statement, and Bylaws.
3.	Adheres to a consistent pro-life medical position and practice.
4.	Is reliable and respects confidentiality.
5.	Oversees the nurse manager and meets with him/her on a regular basis.
6.	Oversees the physician volunteers in the clinic.
7.	Reviews and signs every ultrasound chart or has this done by a physician designee; at his/her discretion, reviews and signs other medical charts (such as pregnancy tests) or has this done by a physician designee.
8.	Reviews and approves clinic medical policies and procedures; drafts clinic standing orders for medical care.
•	Role of the nurse manager 
1.	Must possess a current nursing license and function in accordance with the licensing board of their state.
2.	Agrees with the center's Statement of Faith, Mission Statement, and bylaws.
3.	Adheres to a consistent pro-life medical position and practice.
4.	Is reliable and respects confidentiality.
5.	Operates from strengths but recognizes limitations.
6.	Acquires the knowledge base needed to care for patients and perform duties with excellence.
7.	Provides support, mentoring and medical back up to medical and non-medical volunteers.
8.	Oversees adherence to all policies, procedures and protocols.
•	Role of the ultrasound exam
1.	Because imaging technology continues to advance, the clinic should periodically determine that its ultrasound machine produces quality images comparable to accepted standards of care.
2.	There will be a medical indication and a physician's order for an ultrasound exam.
3.	The clinic will develop protocols for screening and selection of clients for ultrasound exams.
4.	Ultrasound performed by personnel other than a competent physician will be performed according to clinic standing orders.
5.	The medical director may determine that certain medical conditions, gestational age of the pregnancy, or other parameters may exclude a client from an ultrasound exam.
6.	Each clinic will develop an informed consent form for the clients to sign which specifically states the indications for the ultrasound and what information the scan will and especially will not address.
7.	The clinic must stress that the ultrasound exam does not constitute ongoing prenatal care and resources and referrals for prenatal care will be given to the client.
•	Role of Nurses (and X-ray Technicians) in Limited Ultrasound 
Registered Nurses (and if allowed by the state, LPNs and x-ray technicians) may perform ultrasound exams
1.	Nurses must possess a current nursing license and function in accordance with the licensing board of their state. X-ray technicians must be certified and function in accordance with the standards set by their state.
2.	They must possess the body of knowledge necessary to assess the significance of normal and abnormal findings.
3.	They must complete an ultrasound course that adheres to AWHONN, ACOG, or AIUM guidelines.
4.	They must have continual hands-on ultrasound training with a professional skilled in ultrasound until they are deemed competent. This professional may be a competent registered diagnostic medical sonographer, physician, or nurse. Competency should be established according to the written policies and procedures of the clinic.
5.	Prior to performing ultrasound exams, the medical director or designee evaluates the nurse's or x-ray technician's competency, and a letter of competency from the medical director is placed in the individual's file.
6.	The nurse or x-ray technician will undergo ongoing assessment of competency.
•	First Trimester
1.	Using M-mode, fetal heart motion (or lack thereof) is measured and documented.
2.	The uterus is scanned in both the longitudinal and transverse planes. The gestational sac or fetus is imaged and labeled.
3.	The yolk sac, preferably with the fetus in the image is documented.
4.	If multiple embryos are present, the fetal number is documented.
5.	The medical director will decide what additional aspects of a limited scan, including scanning of adnexa, will be done by the nurse or x-ray technician under his/her direction. See appendix for further discussion.
•	Second and Third Trimesters
1.	Using M-mode, the fetal heart motion (or lack thereof) is measured and documented.
2.	Documentation of fetal biometry and fetal scan shall be determined at the discretion of the medical director.
•	Documentation
1.	Written ultrasound report accompanied by videoprint pictures will be completed by the nurse or x-ray technician performing the scan. This is the minimum required documentation. Alternative documentation includes videotape.
2.	Every ultrasound scan will be reviewed and signed in a timely fashion by a physician qualified to read the ultrasound scan.
3.	Clients will be given pictures as determined by the medical director. Any pictures provided should not contain measurements or estimates of gestational age.
4.	At the discretion of the medical director, videotapes should be destroyed after review by physician.
•	Roles of Physician/Sonographer in Ultrasound
Licensed physicians, physician assistants, nurse practitioners, and sonographers will not practice beyond the level of their training.
•	First Trimester
1.	Using M-mode, fetal heart motion, or lack thereof, is measured and documented.
2.	The uterus is scanned in both the longitudinal and transverse planes. The gestational sac or fetus is imaged and labeled.
3.	The yolk sac, preferably with the fetus in the image is documented.
4.	If multiple embryos are present, the fetal number is documented.
5.	The medical director will decide what additional aspects of a limited scan, including scanning of adnexa, will be done by the performing physician, See appendix for further discussion.
•	Second and Third Trimesters
1.	Using M-mode, the fetal heart motion, or lack thereof, is measured and documented.
2.	Documentation of fetal biometry and fetal scan shall be determined at the discretion of the medical director.
•	Documentation
1.	Written ultrasound report accompanied by videoprint pictures will be completed by the physician or sonographer performing the scan. This is the minimum required documentation. Alternative documentation includes videotape.
2.	Every ultrasound scan will be reviewed and signed in a timely fashion by a physician qualified to read the ultrasound scan.
3.	Clients will be given pictures as determined by the medical director. Any pictures provided should not contain measurements or estimates of gestational age.
4.	At the discretion of the medical director, videotapes should be destroyed after review by physician.
Copyright Â© 2005 Focus on the Family All rights reserved. International copyright secured.


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## Lisa Bledsoe (Oct 26, 2010)

Thank you.  Unfortunately, I don't see this addressing what must be included in the documentation for the ultrasound.


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## preserene (Oct 27, 2010)

L.Curtis,  do you mean the documentation by the physician, as regards to clinical or coding  aspect  or both?

Could you please check this web site which could cover what you need:
 Ultrasound. Obstetrical Care Services. BUREAU OF MEDICAID SERVICES with the web site: ahca.myflorida.com/Medicaid/deputy.../ultrasound_OBG_071410.pdf


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