Page 26 - 2022 Risk Basics - Radiology

SVMIC Risk Basics: Radiology

Increasingly, radiologists are recognizing the use of the RIS to allow

documentation of important clinical information and advice that is not
appropriate for the content of the radiology report. Most modern systems

recognize this requirement and have a section whereby this record can
be entered. In addition, thorough documentation is required for coding

and billing purposes.

Radiologists receive information from a variety of sources: the referring
provider, the patient, old records/studies, and multiple specialist

evaluations. All of the information and sources used by the radiologist as
part of his or her evaluation must be documented.

The use and quantities of drugs and contrast media must be well-
documented. Radiation dose information must also be recorded as it may

be needed or used in the future. Similarly, comprehensive reporting of
the measurement or calculation of renal function affords safety for the

patient. In the event there is a problem, the radiologist has an accurate
baseline number.

Overall, complete documentation is best for everyone’s interest. Certainly,

it is helpful from a legal standpoint, but most importantly, it improves the
patient’s healthcare delivery and increases overall patient safety.

Audit Trail

Every electronic health record and other electronic storage/
communication system has an audit trail. The timeline is no longer a

guessing game. Gone are the days of using handwriting experts to try to
determine when and by whom an entry was made in a patient’s chart.

Forensic IT experts can now review the metadata contained within the
EHR and other systems, which is basically the DNA of the system, to

determine everything that occurred in the electronic media.

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