POCUS Note | ICU Ultrasound Documentation

Clinical context

Only details that materially change interpretation.

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Clinical problemAge / sexAdmission / POCUS questionHeight

Weight

Body surface areaAuto

m²

Focused Cardiac findings

Select core findings, then refine the note preview.

Measurements / calculations

SV uses LVOT diameter/VTI; CO adds heart rate; CI uses BSA from Clinical Context.

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Estimated LV systolic functionRV size compared with LVPericardial effusionTAPSE

EPSS

LVOT diameter

LVOT VTI

Heart rate

beats/min

Stroke volumeAuto

Cardiac outputAuto

L/min

Cardiac indexAuto

L/min/m²

Qualitative findings

Choose the closest bedside appearance.

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Global cardiac activityLeft ventricular functionRight ventricular size / functionPericardial fluid / tamponadeVolume status / filling appearanceOther relevant bedside findings

Editable documentation previewLive0/17 findings · 2,927 characters

POINT-OF-CARE ULTRASOUND: FOCUSED CARDIAC

Justification:
This focused cardiac POCUS was medically necessary to immediately evaluate for time-sensitive cardiac pathology, including pericardial effusion, tamponade physiology, severe ventricular dysfunction, right heart strain, or cardiac activity in the setting of acute clinical concern. The exam directly informed immediate diagnostic and therapeutic decision-making at the bedside.

Technique and Documentation:
A focused, point-of-care ultrasound (POCUS) was performed and independently interpreted by the attending provider at the bedside. The interpretation was used strictly for immediate clinical decision-making and real-time management of the patient's acute condition.

Standard focused cardiac images were attained; reference the saved images. Representative images were obtained and saved into the EHR for reference.

Documentation supports AMA/CMS-aligned elements for medical necessity, independent bedside interpretation, real-time clinical decision-making, and image archival.

Measurements / Calculations:
Estimated left ventricular systolic function:
Hyperdynamic / Normal / Mildly reduced / Moderately reduced / Severely reduced

Estimated right ventricular size compared with left ventricle:
Normal / Mildly enlarged / Moderately enlarged / Severely enlarged

Pericardial effusion:
Absent / Trace / Small / Moderate / Large

TAPSE, if measured: ____________________ cm

EPSS, if measured: ____________________ cm

LVOT diameter, if measured: ____________________ cm

LVOT VTI, if measured: ____________________ cm

Heart rate: ____________________ beats/min

Stroke volume, if calculated:
0.785 x (LVOT diameter)^2 x LVOT VTI = ____________________ mL

Cardiac output, if calculated:
Stroke volume x Heart rate / 1000 = ____________________ L/min

Cardiac index:
Cardiac output / Body surface area = ____________________ L/min/m²

Qualitative Findings:
Global cardiac activity:
__________________________________________________________

Left ventricular function:
__________________________________________________________

Right ventricular size/function:
__________________________________________________________

Pericardial fluid or tamponade features:
__________________________________________________________

Gross volume status / filling appearance:
__________________________________________________________

Other relevant bedside findings:
__________________________________________________________

Interpretation and Plan:
Focused cardiac POCUS demonstrates:
__________________________________________________________
__________________________________________________________

Most clinically relevant qualitative finding:
__________________________________________________________

Plan based on bedside interpretation:
__________________________________________________________
__________________________________________________________

Do not rely on AI output for time-critical decisions.