Page 13 - 2022 Risk Basics - Radiology

SVMIC Risk Basics: Radiology

Documentation Issues

Maintaining a well-documented medical record, from both a patient
care and a risk management standpoint, is crucial. A review of SVMIC

radiology claims from the past ten years, where a loss was paid on
behalf of an insured, reveals that documentation issues were a factor

in 21 percent of paid claims. Of these, 75 percent involved inadequate
4
documentation, which had a negative impact on the defensibility of the

care provided to a patient. Case examples include:

• A radiologist provided a definitive diagnosis of hemangioma in

the impression section of the report without suggesting possible
alternative diagnoses. The hemangioma turned out to be a

malignant liver tumor.

• A radiologist failed to note the finding of a retained lap sponge on

the radiology report because it was an “incidental finding” in the
abdomen that was found below the chest x-ray field (he assumed

the lap sponges were dressing used by the nurses on the med-surg
floor).

• A patient, who was being treated with External Beam Radiation
Therapy for anal carcinoma, suffered radiation burns and required

a colostomy plus hyperbaric oxygen in order to treat the burns. The
consent form contained no details of the risks discussed, including

the potential for tissue injury.

In addition to inadequate documentation, case analysis also revealed
instances of erroneous documentation and apparent alterations. In one

example, the radiologist correctly dictated “left kidney mass” in the body
of the report but indicated in the impression that the mass was in the

“right kidney”. The surgeon did not read the entire report and performed a
right nephrectomy.

4 SVMIC Sentinel, Specialty Spotlight: Radiology, October 2016.

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