Page 5 - Diagnostic Radiology - Interpreting the Risks Part Two_Neat

SVMIC Diagnostic Radiology: Interpreting the Risks

Part Two

Key Challenge #2: Documentation

Good recordkeeping is an integral part of patient care and

malpractice defense. The diagnostic specialty of radiology is not
immune to this, and it must be recognized that documentation

should extend beyond the confines of the radiology report.

The radiology report is the radiologist’s primary form of medical

recordkeeping, whether it be a diagnostic report or a written

report of a procedure. As earlier stated, it serves the dual
purposes of communication and documentation. This can
take the form of a handwritten report in the patient notes or,

now more commonly, in an electronic report. This electronic

report is then stored on the radiology information system (RIS).
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. However,
a major shortfall often identified in radiologic documentation is

encountered when no order has been placed on the RIS and,

therefore, the patient does not have an “event”.

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

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