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“Interpretations of diagnostic imaging procedures reported separately for Medicare payment must include, either as a separate document or within the main body of the patient’s record, the following minimum information: Patient’s name and other appropriate identifier (date of birth, Social Security number, record number, etc.).
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The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) considers the radiology report to be part of the medical record because it documents the results of a radiologic test or procedure. 13 In addition, hospitals have specific policies regarding the radiology report as part of the medical record.
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered.
The report should communicate relevant information about diagnosis, condition, response to therapy, and/or results of a procedure performed. 12. The written report should also answer any clinical question raised by the requesting patient-care provider that is relevant to the radiologic study.
Since the passage of the Health Insurance Portability and Accountability Act of 1996 (HIPAA), all patients have a legal right to a copy of their report. The radiology report may generally be viewed as part of the medical record.
The condition of the patient at the completion of the surgery, as well as the disposition (postoperative location of the patient), should be documented in the operative report such as, "The patient is stable in a recovery room," or "The patient is critical in the intensive care unit").
The first step in completing an incident report is to interview all witnesses to the incident. Which scenario will warrant an incident report? A patient tripping over a chair in the waiting room, an employee sticking herself with a used needle, or a medical assistant administering the incorrect medication to a patient.
Incident reporting is the process of documenting all worksite injuries, near misses, and accidents. An incident report should be completed at the time an incident occurs no matter how minor an injury is.
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What Does an Incident Report Need to Include?Type of incident (injury, near miss, property damage, or theft)Address.Date of incident.Time of incident.Name of affected individual.A narrative description of the incident, including the sequence of events and results of the incident.Injuries, if any.More items...•
Common Types of Incident ReportsWorkplace. Workplace incident reports detail physical events that happen at work and affect an employee's productivity. ... Accident or First Aid. ... Safety and Security. ... Exposure Incident Report.
An incident report is an important tool that is used to document any event, condition or situation that may cause injury to people or damage to an organization's property. Incident reports can be paper-based or electronically generated and are a way of capturing and documenting any of the following things: Accidents.
The incident log documents all details about an event, including date, time, what happened, who was involved and who witnessed the event. You should fill out the incident log immediately after an incident.
Reporting and recording are legal requirements. The report tells the enforcing authorities for occupational health and safety (HSE and local authorities) about serious incidents and cases of disease. This means they can identify where and how risks arise and whether they need to be investigated.
NKA is located in the Overview tab under alerts or in Alerts tab.
They should include: 1) All relevant clinical findings. 2) A record of the decisions made and actions agreed as well as the identity of who made the decisions and agreed the actions. 3) A record of the information given to patients. 4) A record of any drugs prescribed or other investigations or treatments performed.
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The written radiology report is the critical service of radiology and should provide clear and concise communication that is understandable by the intended reader. Since increasingly more often the patient is the reader of the report, it is even more important to keep the report clear and concise.
Impression. The abstract is the summary of a scientific report. In a radiology report, the summary has been referred to as the "Impression," "Conclusion," or "Diagnosis" section. Sometimes this summary is an impression, sometimes it is a conclusion or diagnosis, and sometimes it is a concise statement of the findings.
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) considers the radiology report to be part of the medical record because it documents the results of a radiologic test or procedure. 13 In addition, hospitals have specific policies regarding the radiology report as part of the medical record.
One of the 3 most common reasons for malpractice suits against radiologists is failure to communicate results clearly and effectively. 2,3 Poor communication is a common reason patients choose to sue the doctor. 5,6 In some situations, such as mammograms, it is helpful to give a copy of the report directly to the patient, which makes it even more important that the report is clear and understandable. 6,7 If a report is written so that a patient can understand what is said, it is much more likely that a healthcare provider, who depends upon the report to make decisions concerning patient management, will also understand the report. 8
Therefore, recapitulation of the indication for the study at the time of the report dictation is appropriate because it will document the actual reason the study was performed. In addition, many third-party payers and Medicare now require an appropriate indication before they will reimburse for a study.
Every radiologic study has a procedure associated with performing the examination. For most routine studies, the procedure is implied by the title. For example, a routine study such as a "PA & LAT Chest," by accepted use, implies the procedure (posteroanterior and lateral chest radiograph), and a separate "Procedure" section of the report is not necessary. However, a separate "Procedure" section may be convenient to document informed consent, technical limitations, drugs, and isotopes or contrast material associated with the study. Frequently, reports for invasive procedures are best organized in a separate "Procedure" section.
In some institutions, the indication, or reason for the examination, is part of the request for the study and is automatically included in the heading of the report. However, this information may or may not represent the true indication for the study.
It is expected that patient's medical records reflect the need for care/services provided. The listing of records is not all inclusive. Providers must ensure all necessary records are submitted to support services rendered. They may include:
The documentation requirements contents/references provided within this section were prepared as educational tools and are not intended to grant rights or impose obligations. Use of these documents are not intended to take the place of either written law or regulations.