HealthCare News

Diagnostic Imaging

Issue: #398 DEC2017

Topic: Documentation


Appropriate utilization and effective communication are critical components of diagnostic imaging. In addition to Blue Cross Blue Shield of North Dakota (BCBSND) following the “ACR Practice Parameter for Communication of Diagnostic Imaging Findings” as published in 2014, below are some tips to consider and remember when ordering, documenting and communicating any type of diagnostic imaging result:

  • Quality patient care can only be achieved when study results are given in a timely manner to those responsible for the treatment decisions.
  • An official interpretation (final report) should be completed following any examination, procedure or consultation regardless of the performance site (hospital, physician office, mobile unit, imaging center, etc.).
  • Final reports are the definitive means of communicating to the referring physician(s).
  • Documentation of radiological studies should be completed on the day the image is read.
  • Radiology reports become part of the patient’s permanent medical record.

 

Listed below are the required documentation components for radiology reports.

Demographics:

  • Patient’s name
  • Valid order from the referring provider for the specific test performed
  • Date and time of service
  • Name/type of examination
  • Facility or location where study was performed
  • Name and signature of interpreting provider
  • Inclusion of the following additional items is encouraged:
    • Dictation date
    • Date and time of transcription
    • Birth date and/or age
    • Gender

Clinical information:

  • Indication(s) for examination: Reason why the study is being performed and how the results will be used in the patient’s plan of care
  • Procedures performed/materials used: Description of the studies and/or procedures performed and any contrast media (including concentration, volume and administration route), medications, catheters or devices used
  • Views taken
  • Findings:
    • Appropriate anatomic, pathologic and radiologic terminology should be used to describe findings
    • Indication of study quality, i.e., if results are unable to be obtained due to inadequacy of image(s)
    • Pertinent positive findings and/or pertinent negative findings
    • Impression (conclusion or diagnosis):
      • A precise diagnosis should be given when possible.
      • If appropriate, a differential diagnosis should be rendered.
      • Significant patient reaction or complication, if applicable.
  • If there may be the need for follow-up or additional studies, based on the outcome of the initial study, these should be indicated by the ordering provider as part of the original order when applicable.

Source: American College of Radiology