Echocardiography report: Template and interpretation guide

Key takeaways

An echocardiography report records cardiac structure, function, and blood flow from an ultrasound study, using standardized measurements.

Every report covers ejection fraction, diastolic function, right ventricular parameters, valve severity, pericardial findings, and a clinical conclusion.

Normal LVEF is 52-72% in men and 54-74% in women, so reference ranges must be read by sex.

Practice management software like Pabau stores each report inside the patient record, next to appointments, referrals, and billing.

An echocardiography report is the diagnostic document that records what a cardiac ultrasound found. Cardiologists, sonographers, and referring physicians read it to judge heart function, confirm pathology, and decide what happens next. This guide walks through each section of the report and explains how to interpret the numbers. You also get a downloadable template built around American Society of Echocardiography (ASE) standards. Along the way it flags the documentation detail that decides whether the study gets paid for.

What is an echocardiography report?

An echocardiography report is the clinical summary of a transthoracic or transesophageal cardiac ultrasound. It documents chamber dimensions, wall thickness, systolic and diastolic function, valve morphology, pericardial findings, and hemodynamic measurements. The report is the link between image acquisition and clinical action. It tells the referring physician where the heart stands, supports the treatment decision, and stays in the patient record permanently.

A standardized format reduces ambiguity and makes sure nothing important is left undocumented. According to the American Society of Echocardiography, a complete report covers study information, all four chambers, and valve quantification. It also covers aortic and pulmonary measurements, the pericardium, and a clinical summary. Many practices capture those fields during the study itself using digital forms rather than dictating afterwards. If you want the patient-facing view of the study, our guide to the echocardiogram test covers preparation and what the scan involves.

Standard sections and what goes in each

A complete transthoracic study follows the same running order every time. Knowing what belongs in each section helps imagers document fully and helps non-imagers read quickly.

• Patient and study information: Demographics, relevant history, indication for the study, date, and the name of the echocardiographer.
• Left ventricle: Dimensions, ejection fraction, and both systolic and diastolic function.
• Right ventricle: RV systolic function, tricuspid annular plane systolic excursion (TAPSE), and free wall strain.
• Atria: Left and right atrial volumes or dimensions.
• Valves: Morphology and function of all four valves, with severity grading for stenosis and regurgitation.
• Aorta and great vessels: Aortic root diameter, ascending aorta dimensions, and pulmonary artery systolic pressure.
• Pericardium: Presence or absence of effusion, plus its size and hemodynamic significance.
• Conclusions and recommendations: Summary of findings, comparison with prior studies, clinical impression, and next steps.

Many practices now run this documentation through automated workflow templates, which keeps the wording consistent and cuts transcription errors. The same structure applies whether the study was ordered for a murmur, a new symptom, or routine surveillance. Pulling the indication in from the new patient questionnaire saves the sonographer from re-typing history that is already on file.

Left ventricular function and ejection fraction

Left ventricular systolic and diastolic function form the clinical core of the study. Left ventricular ejection fraction (LVEF) is the single most-quoted measurement. It gives the percentage of blood ejected with each contraction and sets the classification of systolic dysfunction.

Diastolic dysfunction describes impaired filling of the left ventricle. The report grades it from I (normal) to IV (restrictive), using mitral inflow Doppler, tissue Doppler, and left atrial volume index. Both sides of function matter, because many patients have preserved LVEF with isolated diastolic dysfunction (HFpEF). Where the study shows a dilated, poorly contracting ventricle, the working diagnosis often codes to I43.

Right ventricular function

Right ventricular (RV) assessment covers systolic function and estimated pulmonary pressure. The RV is harder to quantify than the LV because of its crescent shape. Several parameters now make that assessment reproducible from study to study.

Key RV parameters are tricuspid annular plane systolic excursion (TAPSE, normal >17 mm) and RV free wall strain (typically ≥−20%). The RV index of myocardial performance is the third. An elevated tricuspid regurgitant jet velocity or hepatic vein flow reversal points to raised right atrial pressure. Patient record systems that hold structured echo templates let clinicians trend these numbers and catch RV dysfunction early.

Valve assessment

All four valves are assessed in every standard study. The aortic, mitral, tricuspid, and pulmonary valves are graded for morphology, stenosis severity, and regurgitation severity, using color and spectral Doppler.

Severity grading drives the decisions that follow: medical management, surveillance interval, or referral for intervention. Compliance documentation tools make sure every required assessment is recorded and every follow-up recommendation is tracked to completion.

Normal reference values

Every report needs age- and sex-specific reference values so a measurement can be called normal or abnormal. The ASE/EACVI 2015 chamber quantification guidelines remain the most widely used normative dataset for 2D echocardiography.

Applying these ranges consistently prevents both over-diagnosis and under-diagnosis of cardiac dysfunction. Sports medicine practices lean on them when screening athletes or clearing someone to return to training after a cardiac event. Endurance athletes often show larger cavities and thicker walls, and that remodeling is a normal variant rather than disease.

How to read the report step by step

For clinicians who did not perform the study, reading it in a fixed order is faster and safer. Start with LVEF and systolic function to establish cardiac reserve. Move to diastolic grading and atrial size for filling pressures. Then work through the valves, stopping at anything moderate or severe. Finish with the pericardium and the summary.

1. LVEF and systolic function: Is ejection fraction normal? If it is reduced, how severely?
2. Diastolic function and atrial size: Is filling normal or impaired? Is the left atrium enlarged?
3. Valve assessment: Is any valve stenotic or regurgitant, and does the severity warrant intervention?
4. RV function and pulmonary pressure: Is RV function normal? Is there pulmonary hypertension?
5. Pericardium: Is there an effusion, and is it hemodynamically significant?
6. Clinical summary: What are the main conclusions, and is anything urgent?

Referring physicians in primary care practices often review the study with the cardiologist rather than reading it cold. Telehealth consultations make that conversation easy to schedule, and a standard report structure keeps it short. Where the findings are equivocal, functional testing such as a thallium stress test is often the next step.

Sex differences that change interpretation

Sex differences in left ventricular size and function are well documented, and the report has to account for them. Women have smaller LV cavities and thinner walls than men, even after correcting for body size. Using a single cutoff for both sexes over-diagnoses dysfunction in women and under-diagnoses it in men.

Key differences: normal LVIDd is 3.9-5.3 cm in women against 4.2-5.9 cm in men. LVEF runs 54-74% in women and 52-72% in men. Left atrial volume index, RV dimensions, and aortic root diameter also differ. Measurement tracking that flags out-of-range values against the patient’s sex removes a common source of interpretation error.

When to refer back to cardiology

Some findings need a cardiology opinion quickly. The red flags are severe systolic dysfunction (LVEF <30%) and a newly reduced ejection fraction. A fall of 10% or more from the prior study counts. So do moderate-to-severe valve disease, a significant pericardial effusion, pulmonary hypertension, and a restrictive filling pattern.

Moderate single-valve disease usually means a surveillance study every one to two years. Severe disease prompts urgent evaluation and planning for medical optimization, surgery, or a transcatheter procedure. Automated alerts can flag a critical result and open the referral task the same day. A template that marks abnormal values clearly and states the next step is the simplest safeguard against a missed finding.

Pericardial assessment and findings

The pericardium normally holds a small amount of fluid, up to about 50 mL. The report records the presence, size, and hemodynamic effect of any effusion. Small effusions are often silent. Moderate ones can impair filling, and large or loculated collections risk tamponade and may need urgent drainage.

Tamponade physiology shows on echo as early-diastolic right atrial collapse, RV diastolic collapse, marked respiratory variation in mitral and tricuspid inflow, and dilated hepatic veins. Pre- and post-procedure documentation usually includes serial studies after pericardiocentesis or surgery, to confirm the effusion is resolving.

CPT codes and billing context

Practices billing for an echo study have to match the report to the right Current Procedural Terminology (CPT) code. CPT 93306 covers a complete transthoracic echocardiogram with 2D imaging, M-mode, and spectral and color Doppler. CPT 93307 covers a complete transthoracic echocardiogram with 2D imaging, without spectral or color Doppler. CPT 93308 covers a follow-up or limited transthoracic echocardiogram (fewer than nine required structures documented). Transesophageal studies are coded separately, starting with 93303 for congenital anomaly work.

The report has to itemize every modality, measurement, and assessment performed to support the code billed. Stress echo is billed under its own family, alongside exercise testing codes such as 93015. Coders new to cardiology often keep a medical coding cheat sheet beside the report for exactly this reason.

Integrated claims management that links the structured report to the billing code cuts denials and protects revenue. Templates that enforce complete documentation also keep the practice ready for an audit.

How Pabau keeps echo reports inside the patient record

In most practices the echo report lives somewhere other than the patient’s chart. It sits in the imaging system, in a PDF folder, or in an email to the referrer. Comparing today’s ejection fraction with last year’s then means opening three systems, and the surveillance interval depends on someone remembering it.

Practice management software like Pabau puts the report in the record itself. The sonographer completes a structured echo form during the study. The finished report then attaches to the patient’s timeline, next to prior studies, referrals, and appointments. Measurements entered as fields can be trended, so a falling ejection fraction is visible rather than buried in prose.

From there the routine work runs itself. The report goes to the referring physician automatically, and the surveillance study is booked before the patient leaves. The documentation is already attached when the claim is prepared. Your team stops chasing paperwork and gets the follow-up right more often.

Keep every echo report in the patient record

Pabau captures echocardiography findings on structured forms, files them in the patient’s chart, and links them to referrals and claims. Your team can trend measurements over time and send reports to referring physicians without extra admin.

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Conclusion

The value of an echo report is decided by how consistently it is written, not by how much detail it contains. A report that always covers the same parameters, in the same order, against sex-specific ranges reads in two minutes. That holds even for a clinician who never saw the images.

The trade-off worth remembering is that structure takes discipline up front. Filling in fields feels slower than dictating a paragraph. It pays back at the follow-up study, at the referral, and at the point the claim is reviewed. Download the echocardiography report template above and use it for the next study your practice performs. Book a demo to see how Pabau files echo reports in the patient record and keeps surveillance follow-up on schedule.

Continue your research

Need the patient-facing view of the study? Echocardiogram test walks through preparation, what happens during the scan, and how results are explained to patients.

Assessing functional capacity as well as structure? Cardiopulmonary exercise testing shows what an exercise study adds once the resting echo is normal.

Want the observations recorded before the scan? Vital signs record gives you a printable sheet for baseline readings at every visit.

Tracking recovery in cardiac patients? Heart rate recovery chart by age sets out the expected recovery ranges for each age band.

Standardizing bedside assessments too? Neuro checks nursing assessment gives nursing teams a structured format for repeated observations.

Frequently asked questions