The principles and techniques of real-time imaging with phased array ultrasound scanners are reviewed. Topics include 1) the geometric optics of beam steering and focusing with a linear array in the transmit and receive modes; 2) limitations on image data acquisition due to ultrasound propagation velocity; 3) optical diffraction theory for linear arrays including effects of amplitude grating lobes. Limitations on the image quality of phased array imaging systems are also discussed, including 1) nonideal response of array transducers; 2) target ambiguities caused by phase error grating lobes; 3) refraction errors; 4) delay line design. Finally, an analysis is presented of current techniques for improving ultrasound image quality using phased array methods including phase compensation, spatial compounding, frequency compounding, and parallel processing.