Attachment 7 - Communication of Diagnostic Reports.pdf

Communication of Diagnostic Reports

SOP 115-07

West Palm Beach Healthcare System West Palm Beach, FL 33410

Signatory Authority:

Chief of Imaging Service

Responsible Owner:

Chief of Imaging Service

Service Line(s):

Imaging Service

Effective Date:

June 22, 2022

Recertification Date:

June 30, 2022

1. PURPOSE AND AUTHORITY

a. The purpose of this standard operating procedure (SOP) is to establish procedures on communicating diagnostic radiology findings (READ-BACK). This SOP must be followed by Radiologists who communicate diagnostic radiology findings.

2. PROCEDURES

a. Written Interpretation.

(1) Will be available in the patient’s electronic medical record following dictation and verification. Reports shall be verified as soon as possible following dictation but in all cases within currently applicable VHA performance measures. Chief, Imaging and/or his/her designee shall verify reports in “unverified” status if the interpreting radiologist is not available to verify such reports. Such situations occur frequently with consultant radiologists, contract radiologists and staff radiologists.

(2) The following items will be reported as a minimum, if applicable:

a) Name and Social Security Number

b) Name if referring physician(s) or other health care provider

c) Name or type of examination

d) Documentation of informed consent, if obtained

(3) Body of the report

a) Procedures and material

b) Description of the studies and/or procedures

c) Contrast media (include type, amount, route concentration, adverse reaction)

June 22,2022 SOP 115-07

d) Radiation dose (when applicable)

e) Catheters and devices used

f) Adverse events

g) Complications

h) Indications for Invasive Procedures

i) Name, time, route, and dose of sedation given to patient

(4) Findings

a) Use precise anatomic and radiologic terminology to describe the findings accurately

(5) Limitations

a) Where appropriate, identify factors that can limit the sensitivity and specificity of the exam

(6) Clinical Issues

a) Address or answer any pertinent clinical issues raised in the request (i.e., patient unable to hold still or hold breath- reasons for suboptimal study)

(7) Impression

a) Include “impression” section for each report

b) Precise diagnosis, when possible

c) Differential diagnosis, when appropriate

d) Recommend follow-up and additional diagnostic studies to clarify or confirm impression

(8) A diagnostic code will be assigned to all radiographs during dictation (See attachment B)

a) When specific codes are entered, the referring provider will receive a “view alert” over the computer. This will identify the patient and advise the provider that there is a significant finding on the radiograph(s).

b. Direct Communication

(1) In adherence with the American College of Radiology Practice Guidelines, non-routine communications are to be handled in the manner most likely to reach the attention of the treating or referring physician in time to provide the most benefit to the patient.

a) If there are urgent, emergent, or significant unexpected findings, the Radiologists will communicate directly with the referring physician. These findings will be Read-Back by referring Physician and/or designee to reporting Radiologist. If they are unavailable, their supervisor, service chief, or MOD will be notified respectively (See attachment C). Critical tests results will be communicated and read-back process enacted within four (4) hours of result availability.

b) Documentation of all direct communication/Read-back is appropriate and will be entered into the report, to include specifically: the name of the person to whom the communication was delivered, along with the time and method of delivery.

c) Any significant discrepancy between an emergency or preliminary report and the final written report should be promptly reconciled by direct communication with the referring provider. If they are unavailable, their supervisor, service chief, or MOD will be notified respectively.

3. ASSIGNMENT OF RESPONSIBILITIES

a. The Chief, Imaging Service, has the overall responsibility for establishing standards and practices related to this SOP. The Chief will also be responsible for the distribution of Attachment A of this SOP to all staff radiologists.

b. The Radiologists are responsible for following these practice standards when communication diagnostic radiology findings.

4. DEFINITIONS

NONE

5. REFERENCES

a. American College of Radiology Guidelines for Communication of Diagnostic Imaging Findings, 2020, LINK

b. MCM 548-11-122, Ordering and Reporting Test Results, dated March 19, 2022, LINK.

6. REVIEW

This SOP must be reviewed minimum at recertification, and when there are changes to the governing document or process.

7. RECERTIFICATION

This SOP is scheduled for recertification on or before the last working day of June 2027.

In the event of contradiction with national policy, the national policy supersedes and controls.

8. SIGNATORY AUTHORITY

/s/David M. Mullin MD Chief, Imaging Service Date Approved: June 22, 2022

NOTE: The signature remains valid until rescinded by an appropriate administrative action.

DISTRIBUTION: SOPs are available at the “Document Control System (DCS)” in the West Palm Beach VA Medical Center Intranet Main Page. West Palm Beach VAMC Home

Attachment A

Communication: Diagnostic Radiology Report

Communication is a critical component of the art and science of medicine and is especially important in diagnostic radiology. Radiographs are to be interpreted with appropriate information to promote optimal care.

A. Written Communication

1. Name and Social Security Number

2. Name of referring physician(s) or other health care provider

3. Name or type examination

4. Dates of examination

5. Documentation of informed consent, if obtained

6. Body of report

a) Procedures and Materials

1. Description of the studies and/or procedures

2. Contrast media (include type, amount, route, concentration, adverse reactions)

3. Catheters and devices used

4. Adverse events

5. Complications

6. Indications for Invasive Procedures

b) Findings

1. Use precise anatomic and radiologic terminology to describe the findings accurately

c) Limitations

1. Where appropriate, identify factors that can limit the sensitivity and specificity of the exam

d) Clinical Issues

1. Address or answer any pertinent clinical issues raised in the request

e) Comparative Data

1. Comparisons with previous exam, when applicable

7. Impression

a) Include “impression” section for each report

b) Precise diagnosis, when possible

c) Differential diagnosis, when appropriate

d) Recommend follow-up and additional diagnostic studies to clarify or confirm impression

8. A diagnostic code will be assigned to all radiographs during dictation (see attachment B)

a) When specific codes are entered, this will identify the patient and advise the provider that there is a significant finding on the radiograph(s).

B. Direct Communication

1. If there are urgent, emergent, or significant unexpected findings, the radiologist will communicate directly with the referring provider. If they are unavailable, their supervisor, service chief or MOD will be notified respectively.

2. Documentation of all direct communication is appropriate and will be entered into the report.

3. Any significant discrepancy between an emergency or preliminary report and the final written report should be promptly reconciled by direct communication with the referring provider. If they are unavailable, their supervisor, service chief, or MOD will be notified respectively.

Attachment B

Diagnostic Codes

90 UROLOGY PRIORITY This code will also alert the UROLOGY PRIORITY Group

95 HCC PRIORITY

100 PULMONARY PRIORITY This code will also alert the PULMONARY PRIORITY Group

1000 No alert required

1001 Significant Abnormality, Attn Needed

1002 Critical Abnormality

1003 Possible Malignancy

Mammography

1100 BI-RADS CATEGORY 0 Incomplete: Need Additional Imaging Evaluation

1101 BI-RADS CATEGORY 1 Negative

1102 BI-RADS CATEGORY 2 Benign

1103 BI-RADS CATEGORY 3 Probably Benign

1104 BI-RADS CATEGORY 4 Suspicious

1105 BI-RADS CATEGORY 5 Highly Suggestive of Malignancy

1106 BI-RADS CATEGORY 6 Known Biopsy Proven Malignancy

Aneurysm

1200 ABDOMINAL AORTIC ANEURYSM NOT PRESENT

(The maximum width of the intrarenal aorta is less than three centimeters)

1201 ABDOMINAL AORTIC ANEURYSM PRESENT

(The maximum width of the infrarenal aorta is at least three centimeters)

1202 DOES NOT SATISFY SCREEN FOR AAA

(Exam is not technically adequate for AAA screening)

Attachment C

Urgent/Emergent Diagnosis List

The following list includes but is not limited to common urgent, emergent, and significant unexpected findings, which the radiologist will directly communicate to the referring provider. If the referring provider is unavailable, their direct supervisor will be notified.

1. New or progressed intra-cranial hemorrhage

2. New brain infarct

3. New intracranial aneurysm

4. Acute Hydrocephalus

5. New critical carotid stenosis

6. Cardiac tamponade

7. Congestive heart failure with new acute alveolar edema

8. Active pulmonary embolism

9. Acute pneumothorax

10. New pulmonary embolism

11. Unsuspected or severe pneumonia

12. Empyema

13. Acute aortic dissection

14. Abdominal aortic aneurysm: new and greater than 5cm, rapid annual growth or rupture

15. Perforated hollow viscus

16. Unsuspected obstructive uropathy

17. Acute appendicitis

18. Acute cholecystitis

19. Intra-abdominal abscess or hemorrhage

20. Acute biliary obstruction

21. Unsuspected or outpatient acute diverticulitis

22. Ectopic pregnancy

23. Testicular torsion

24. Acute spinal cord compression

25. Unsuspected or outpatient acute fractures/dislocations

26. New deep venous thrombosis

27. New neoplastic processes

28. Compromised catheters, tubes, or wires

Attachment D

Reconciliation and Communication of Report Discrepancies

1. CPRS (Computerized patient record system) GUI (graphical user interface) contains the progress notes for all patient encounters. All emergency room notes include initial interpretation of x-rays ordered by emergency room physicians after-hours.

2. If there are urgent, emergent, or significant unexpected findings, the radiologists will communication directly with the referring physician. If they are unavailable, their supervisor, service chief, or MOD will be notified respectively (see attachment C).

3. Documentation of all direct communication is appropriate and will be entered into the report.

4. Any significant discrepancy between an emergency or preliminary report and the final written report should be promptly reconciled by direct communication with the referring provider. If they are unavailable, their supervisor, service chief, or MOD will be notified respectively.

5. Relevant telephone numbers:

(a) Hospital Operator (back door-direct) x7676 (561-422-7676)

1. The hospital operator can locate any provider or the MOD (medical office of the day)

(b) Emergency Room x5705/5706 (561-422-5705)

(c) Emergency Room doctor x5431/7581/8798

(d) Triage x8210

6. READBACK (require report recipient to read back what he/she has written for confirmation) and document “READBACK” in report.