Reporting & Documentation

Governance & reporting

Reporting & Documentation

All POCUS scans must be documented with a structured report in the patient record. We have created report forms based on the FUSIC and BSE reporting standards — these are available as electronic forms in EPR Sunrise at Salford, and as paper forms at Fairfield. Search for POCUS, echo, or ultrasound to find them.

Accredited operators

Complete and submit the report form for every scan. You are responsible for the findings and the report.

Unaccredited operators

Only complete a report form if the scan is clinically urgent and cannot wait for an accredited operator. The form includes a section for review comments — an accredited trainer must review and countersign as soon as possible.


Salford RoyalEPR Sunrise — electronic forms

Finding the form

Electronic POCUS report forms are available in EPR Sunrise. Open the patient’s chart and use the form search — search for POCUS, echo, or ultrasound to bring up the available forms.

Completing the report

  1. Open the patient’s chart in EPR Sunrise.
  2. Navigate to the forms section and search for POCUS, echo, or ultrasound.
  3. Select the appropriate form for the scan performed (e.g. POCUS Heart, POCUS Lung).
  4. Complete all required fields: operator name and accreditation level, indication, views obtained, findings, and conclusion.
  5. Include a statement of where images are stored.
  6. Sign and submit the form to the patient record.
The completed form becomes part of the permanent clinical record and is accessible to all treating clinicians.

Fairfield GeneralPaper forms

Finding the form

Paper forms are kept in the black ring binder at the main ICU station or in A&E Resus.

Completing the report

  1. Take a paper POCUS report form from the black ring binder.
  2. Select the appropriate form for the scan performed (e.g. POCUS Heart, POCUS Lung).
  3. Complete all required fields: operator name and accreditation level, indication, views obtained, findings, and conclusion.
  4. Include a statement of where images are stored.
  5. File the completed form in the patient’s notes.
The completed form becomes part of the permanent clinical record and is accessible to all treating clinicians.
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