Page 19 - Diagnostic Radiology - Interpreting the Risks Part One

SVMIC Diagnostic Radiology: Interpreting the Risks

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 2006-2015, 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,
5
75 percent involved inadequate 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 on
the radiology report because it was an “incidental finding”

in the abdomen that was found below the chest x-ray
(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

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

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