Date:
Patient:
MRN:
Clinician: (Perinatologist, Radiologist)
Reason for Visit:
Fetal CNS ultrasound (routine or targeted)
(Optional) Specific reason for evaluation (suspected anomaly, family history)
History of Present Illness:
Gestational age at the time of ultrasound
Maternal age and parity (number of previous pregnancies)
Prenatal screening results (serum markers, nuchal translucency)
Family history of neural tube defects (NTDs) or other CNS anomalies
Past Medical History:
Previous pregnancies (miscarriages, terminations, birth defects)
Maternal medical conditions (diabetes, infections)
Ultrasound Findings:
Document the following details of the fetal CNS evaluation:
Brain:
Biformed (two hemispheres)
Ventricles (size and symmetry)
Choroid plexus (normal appearance)
Corpus callosum (presence and integrity)
Cisterna magna (normal size)
Midline (no midline shift)
Spine:
Vertebral column visualization (complete and normal alignment)
No evidence of spina bifida or other spinal anomalies
Briefly describe any other relevant anatomical findings on the ultrasound.
Assessment:
Interpret the ultrasound findings in the context of gestational age and any risk factors.
If normal: Reassure the patient regarding the fetal CNS development at this gestational age.
If abnormal: Describe the specific abnormality identified and its potential significance.
Consider including differential diagnoses based on the findings.
Plan:
Outline the next steps based on the ultrasound findings:
Normal study: Continue with routine prenatal care.
Abnormal study: Discuss the findings with the patient and offer genetic counseling.
Consider further prenatal testing (amniocentesis, chorionic villus sampling) if indicated.
Schedule follow-up ultrasound at a specific gestational age to monitor the anomaly.
Referral to a specialist (fetal medicine specialist, neonatologist) for further evaluation and management.
Education:
Document any education provided to the patient regarding:
The purpose and limitations of a fetal CNS ultrasound
The meaning of the ultrasound findings (normal or abnormal)
The importance of prenatal care and follow-up
Notes:
Include any additional relevant information not covered above, such as the patient’s emotional response to the findings and any support resources offered.
Disclaimer: This is a template and should be adapted to the specific needs of each patient. Ultrasound interpretation requires expertise, and this template cannot substitute for a qualified healthcare professional’s assessment.