36C25818Q0069-005.pdf

Southern Arizona VA Health Care System (SA V AHCS)

Radiology Service Line

Tucson, Arizona

Radiology Service Standard Operating Procedure (SOP) No. 30

SOP 114-17-30

July 21, 2017

PROVIDING RADIOLOGIC EXAMINATION NOTIFICATION REPORTS TO

REQUESTING PHYSICIANS

1. PURPOSE: A policy and procedure are described for reporting results of radiologic examinations and for immediately notifying providers when results may require urgent care.

2. POLICY: Routine radiologic examination turnaround time goal is to provide completed and verified reports within 48 hours of testing for 90 percent or more of all cases. Examinations with findings that indicate urgent clinical management may be needed must be reported immediately by verbal notification to an appropriate licensed healthcare provider.

3. RESPONSIBILITY:

a. Chief, Radiology Service Line is responsible for overall compliance of this policy.

b. Radiologist are responsible for notification and documentation of results and notification.

c. Licensed Clinical provider receives the reports and reads back the results.

d. Emergency Department (ED) Physician or Senior Clinical Officer (SCO) receives urgent results when clinician/nurse is unavailable and is responsible for appropriate follow up action.

e. Chief Technologist or Quality Manager (QM) coordinator is responsible for audits.

4. PROCEDURE:

a. Reporting of radiologic interpretations is performed whenever possible using voice recognition (Power scribe) and Vista Imaging systems.

b. An alert system utilizing diagnostic codes when reporting results is used for providing electronic notification. The following codes generate an electronic alert to the requesting physician.

(1) Code 4 is an abnormality that may indicate a significant problem, but which does not require immediate clinical intervention. An example of a Code 4 is a solitary lung nodule.

Attachment 4

SOP 114-17-60

SOP 114-17-30

(2) Code 5 is an abnormality that indicates a significant problem that requires immediate notification and for which the clinician is immediately notified. Examples of a Code 5 include free air, pneumothorax, or intracranial hemorrhage.

(3) Code 9 is an abnormality that includes malignancy as a diagnostic possibility.

(a) In addition to electronic notification, cases in the code 5 category require immediate verbal notification ofresults to an appropriate provider as outlined in SOP 114-:XX-55, Critical

Tests and Values Policy and Listing. The healthcare provider must record and read back the complete study/results communicated to ensure accurate verbal communication of results. The written report must include the name of the notified provider as well as a date and time of verbal communication.

(b) Appropriate notification of significant abnormalities will be monitored periodically through an audit process and reviewed by the Chief, Radiology Service Line.

5. RESCISSION: None.

6. REVIEWDATE: July 2019.

Edward G. Ohnesorgen

Chief Radiologic Technologist

Gonconcur

Anil K. Malik, MD

Chief, Radiology Service Line