Page 28 - 2022 Risk Basics - Radiology

SVMIC Risk Basics: Radiology

Finally, if a provider shares his or her login information with a staff

member or permits someone else to sign an EHR electronically using
e-signature, it will appear from the audit trail that it was the provider

whose login information was used who accessed the EHR or signed
the record. This could be problematic in a claim where the record is in

question. It could also be a violation of third-party payer contracts. SVMIC
strongly recommends that logins and passwords should not be shared.

Elements of a Well-Written Radiology Report

An accurate, intelligent, concise, and detailed report that is reliably
delivered to the referring provider (and sometimes the patient as well) as

soon as possible is a laudable goal that is not often achieved. Let’s look at
some elements of a good radiology report.

☐ Comprehensive Format

A radiology report should include demographics, relevant clinical

information, clinical issues, comparison studies and reports, procedures
and materials, potential limitations, findings, and overall impression.
12

☐ Appropriate Content

Nonstandard abbreviations should be avoided to preclude ambiguity.
In most cases, significant misinterpretation by referring physicians can

be avoided by noting the contextual implications of an abbreviation.
However, it can be frustrating for the referring physician to spend time

trying to decipher the meaning of a nonstandard abbreviation. Similarly,
numeric dating should be avoided to prevent errors related to an alternate

dating system. For example, use “Aug. 8”, rather than “8/8” .

12 ACR Practice Guidelines for Communication of Diagnostic Imaging Findings, Introduction, (revised 2020).

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