The sonographer or examiner should:

• Review data acquired during the evaluation to ensure that a complete and comprehensive evaluation has been performed and documented.
• Explain and document any exceptions and limitations to the evaluation protocol (i.e., study limitations, omissions or revisions).
• Record all technical findings required to complete the final diagnosis in the patient’s medical record
• Document exam date, clinical indication(s), technologist performing the evaluation and exam summary in the patients’ medical record.
• Review previous exam documentation and compare to the current exam to document any change.