Effective Documentation for Interpreting Radiology Procedures
Radiology procedures such as imaging with x-rays help physicians diagnose and treat medical conditions. Radiology reports are essential to communicate the results of the imaging procedure to the referring physician so that appropriate treatment can be given as early as possible. These reports also remain as a legal record of the episode of care. Prepare your reports concisely and use clear, unambiguous language during radiology transcription. Avoid over-documentation. It is neither necessary nor appropriate to include extraneous details as it may detract the referring physician from relevant findings. Let’s take a detailed look into the documentation elements required to interpret radiology procedures better.
Important Documentation Elements
Radiology reports should minimally include the following details:
- Patient's name, date of birth or age and sex
- Referring physician’s name
- Date and time of the study
- Patient history
- Reason for the study
The other important documentation elements are as follows:
- The extent of exam (limited or complete), the number and type of views taken (bilateral, left, right) and any contrast media and/or radiopharmaceuticals used.
- Specific administered activities, concentration, volume and route of administration (intravascular, intra-articular, or intrathecal) when applicable and medications, catheters or devices used if they are not recorded elsewhere. Examples for this are given below.
- A separate description of each radiologic study performed on the patient
- Recommendations for a follow-up exam or additional diagnosis, if required
- Comparison with previous examinations and report as appropriate
- An indication of any limitations in the examination (for example, poor image quality or patient preparation)
- Summary of conversation with other healthcare providers
- Any known significant patient reaction or complication
- Findings, results, impressions and conclusions
- Identify factors that may compromise the sensitivity and specificity of the examination
- Address clinical issues. If there are any factors that prevent answering of the clinical question, you should state those factors explicitly.
- The impression (conclusion or diagnosis) of the interpreting physician should be included under ‘impression’ section
You should be very careful in documenting the finding, its level of criticality, the person notified, and the date and time of notification. Use appropriate anatomic, pathologic and radiologic terminology to describe the findings. It is also recommended to document the date of the dictation and date and time of transcription in addition to the radiologist’s signature.
Significance of EHR Transcription
Without a valid interpretation and report, it will become difficult for the referring physicians to diagnose the relevant condition and recommend other tests or provide appropriate treatment. Many practices follow a standard format for all radiology reports to ensure that all the required elements are documented. Electronic health records or EHRs support standardized documentation and make it easy for physicians to prepare and access documents whenever needed. However, two challenges still plague EHR documentation such as:
- Limited narrative description, which itself hampers better interpretation of radiology procedures
- Copying and parting information frequently to save time can be detrimental to the accuracy of the documentation
An integrated approach of EHR and transcription can solve these challenges due to the experts’ intervention. EHR transcription involves transcribing the radiology procedures with the help of well-trained and experienced medical transcriptionists, reviewing the transcribed data with proofreaders and editors and populating them into relevant fields within electronic records. This approach will ensure the accuracy and comprehensiveness of the documentation while harnessing the unique possibilities of EHR.
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