When we are given history, or when we can easily obtain one, please enter that history in your report. This can be easily accomplished with a template with a history field. If there is no history, delete that field rather than actually say "no history provided". When providing history, think of what our billing coders would want to know - which is a symptom or a diagnosis from the study; not a "rule out".
Always check the Study Comments field (i-box) when reading an exam. It may contain important information such as a resident preliminary report, or when and to whom a report was called. Any pertinent information should be reflected in your dictated report, either by dictating, or simply by copying and pasting. This is often important for documenting quality issues as our reports are searchable but Study Comments content is not.
Background:Outside exams sent to OHSU PACS that do not identically match the OHSU patient Name and birth date do not automatically get linked to the OHSU record number, and therefore do not automatically show up as prior exams in PACS. In some cases, OHSU patients assigned a new medical record number (such as some trauma entries) also do not get linked by the time of interpretation to the prior exams.
Please have a low threshold to search under the patient name for prior exams, especially when finding pathology that might have been previously imaged, or when the history mentions a prior exam or to compare to a prior exam. When comparison studies are found under a different medical record number, please contact the image library to have them link these exams permanently in pacs to the OHSU medical record number:
- By phone 4-8631 M-F 6:30 am – 6:00 pm.
- or by email anytime email@example.com. Provide patient name, OHSU medical record number (for current exam) and outside medical record number if available, or hospital of origin for prior exam. Note that linking won't occur until next business day.
If you are made aware of priors but are not dictating the exam, leave a note in the study comments (i-box) section for the person reading the exam.
Critical results are urgent, unexpected, or unknown imaging findings that are life threatening and may require urgent intervention, and therefore require direct communication to the referring clinician.
These results must be called to the referring clinician within 30 minutes of discovery. Document communication in the report with "macro verbal".
This is part of National Patient Safety Goal 02.03.01 of communication results to the right person on time.
This is for formal trauma system activations. This is not for general ED films with a history of "trauma". For these formal activations, which can be seen in the order on Impax as "TRAUMA ACTIVATION PAGE 10696," the interpreting radiologist will page the Trauma Chief pager 10696 and give a verbal report to whoever answers that page. We will include in our formal report the name of this person. We will also include in our report any pertinent information that may be in the Impax Study Comments ("ibox") such as the names of other recipients of a verbal report. When the person who actually ordered the trauma study is not on the trauma team (often an ED physician), the radiologist will give that name along with our verbal report, and the trauma service will pass the radiologic findings on to that person as part of their handoff. When the trauma person is occasionally too busy to do this, they will ask the radiologist to make that second call. Radiologists will not communicate critical findings as text pages.
When paging the trauma chief, include in the page the phrase "rad results...." . This is more efficient for all involved.
Some exams get an initial resident, fellow, or faculty report that may be reflected as a Study comments (i-box) entry or a dictated preliminary report. If the final faculty report differs in a potentially significant way, then the existence of this difference must be acknowledged in the final faculty report. This can be as simple as "This result, which differs from the preliminary result, was telephoned to Dr. X at time Y."
These rules govern certain statements that need to be in our reports, as failure to do so will result in our not getting paid. This relates to billing not teaching:
Exams less than 5 minutes:
By definition the entire exam is critical.
Either the resident (trainee) or faculty can say (attest) that faculty was there the whole time.
Exams over 5 minutes:
Those that have a critical portion include biopsy, drainage, use of fluoroscopy, contrast administration other than iv.
Only the faculty can state that they were present for the critical portion of such an exam.
Include this in your dictations. The technologists will annotate the first of your fluoro images that they send to PACS with this time. If you send no images to PACS, they will send a blank image with the fluoro time. This is an important regulatory matter that takes little time.
Avoiding communication problems
Please read intradepartmental email communications promptly so that everyone has consistent information regarding departmental updates and/or procedural changes. Such emails, generally from the Chairman or the QA Committee, generally involve operational updates too urgent to await a subsequent faculty meeting.
Outside studies, including VA studies, that have been scanned into or placed into our film library
Operative cholangiograms and retrograde urographic studies, unless specifically requested by the operating surgeon.
Exams specifically requested not to be read ("Do Not Read") by persons authorized by the medical staff office to make such a request including but not limited to research protocols.
"Red folders" are requests for report addendums by our coders, mostly sent to faculty by e-mail now. These are administrative deficiencies in reports that can preclude payment for our services.
Faculty are expected to complete "red folders" within 5 business days, excluding vacation, holidays, and conferences.
Most common reasons are:
- The aorta and IVC are not mentioned on a complete abdomen ultrasound report.
- Spectral Doppler if used is not mentioned in the technique section of the report.
- Specific details of administered contrast are not included in the report.
- The bladder is not mentioned on a kidney/bladder ultrasound report.
- Physician presence is not documented in procedure reports.
- 3D reconstructions are not mentioned (include whether done on independent workstation or scanner console).
- The most common reason is that the exam title is missing, or one is present but it doesn't match the exam title provided by the hospital.
Staff may need to help educate residents about this by showing them your red folders.