S02 - Attachment 7 - Numbered Memorandum 114-02-19 Reporting Imaging Exam Results.docx

Attachment 7

REPORTING IMAGING EXAM RESULTS

1. PURPOSE: To have in place a communication system and strategy to reduce adverse events that result from delays in communicating diagnostic imaging results.

2. BACKGROUND: Diagnostic Imaging Service is committed to reporting exam results in a timely manner so that appropriate and effective therapeutic action(s) may be taken.

3. POLICY: It is the policy of Mann-Grandstaff Veterans Affairs Medical Center (MGVAMC) that imaging exam results be communicated to the ordering and treating practitioners within a timeframe that allows prompt attention and appropriate action(s).

4. PROCEDURES:

a. All imaging exams performed at this facility are ordered in the electronic health record (EHR). Orders are not accepted unless they indicate the reason for the study, clinical history, and contact information.

b. The results of all imaging studies performed at this facility are entered and verified in the EHR.

c. Important findings that require urgent attention are immediately and directly communicated to the treating practitioner. Direct communication consists of a face-to-face or telephone conversation. The time and means of such communication, and the name of the person contacted, is entered in the EHR either as a note or within the study report by the interpreting physician. If the ordering practitioner cannot be contacted, the report is directly communicated to the practitioner’s service chief or the Medical Officer of the Day (MOD). Findings that may require direct communication and urgent attention include, but are not limited to:

(1) Any finding that has the potential for serious harm, and that requires an urgent intervention or change in patient management.

(2) Any finding that might result in prolongation of patient pain or discomfort.

(3) Any finding that would result in the cancellation of on-going or imminent treatment.

d. Important study findings that may require a change in patient management, but not necessarily within an urgent timeframe, may be communicated by either direct documented communication or by the appropriate view alert which is entered by the interpreting physician according to the following standard codes and will generate a view alert to the ordering provider.

(1) Diagnostic Code 5 – ABNORMAL.

(2) Diagnostic Code 6 - ABNORMAL, ATTENTION NEEDED.

(3) Diagnostic Code 1001 - FOLLOW-UP/FOLLOW-UP EXAM NEEDED.

(4) Diagnostic Code 1024 - AMENDED REPORTS REVIEW IS REQUIRED.

(5) Diagnostic Code 1002 - CRITICAL RESULTS-PHYSICIAN NOTIFIED.

(6) Diagnostic Code 1201 - ABDOMINAL AORTIC ANEURYSM GREATER THAN 3.0 CENTER OF MASS (CM).

5. RESPONSIBILITIES:

a. Deputy Chief of Staff (DCOS) and Chief of Staff (COS) are responsible for the oversight of Diagnostic Imaging Service.

b. Chief, Diagnostic Imaging Service is responsible for instructing staff regarding policies and procedures for communication of imaging test results.

c. Diagnostic Imaging radiologists are responsible for:

(1) Ensuring that verified test result reports are available in the medical record in a timely manner.

(2) Identifying and communicating emergent test results to the ordering practitioner or the practitioner’s surrogate or supervisor as appropriate. Documenting the time, means of such communication, and the name of the practitioner contacted in the medical record.

(3) Identifying and communicating abnormal test results that may be treated in a non-urgent time frame using direct (telephone or face-to-face) or electronic (view alerts) communication.

(4) Knowing which diagnostic codes trigger a mandatory view alert.

d. Ordering practitioners are responsible for:

(1) Placing the initial order in the EHR with adequate history.

(2) Addressing results of interpreted radiology findings.

(3) Assigning a surrogate to receive abnormal test result notifications when they are not available to review results in a timely manner (the default surrogate is the service chief).

e. Quality Management Technologist is responsible for:

(1) Weekly audit of view alerts generated for diagnostic code 6, Abnormal, Attention needed. Ordering providers are informed via additional view alerts for diagnostic code 6. Where no primary care provider has been assigned, the Chief, Medicine Service, or designee, is notified with an additional view alert.

(2) Performing weekly audits of view alerts generated for diagnostic code 1001, Follow-up/Follow-Up Exam Required, to ensure that the requesting provider has acknowledged receipt and appropriate action(s) have been initiated. If no primary care provider is assigned, the Chief, Medicine Service, or designee, will be sent a view alert.

(3) Performing monthly audit of diagnostic code 1002, Critical Results, to ensure reading radiologists have requested provider acknowledgement of critical results and read back the results. The interpreting radiologists will dictate in the report “Read back ok” and time of communication as per Joint Commission requirements.

(4) Reporting the results of these audit’s weekly to the Chief, Diagnostic Imaging for further action as indicated.

6. REFERENCE: American College of Radiology (ACR) Council, revised October 1, 2014 (Resolution 11), ACR Practice Parameter for Communication of Diagnostic Imaging Findings

7. RESCISSION: Numbered Memorandum 114-02-16, dated June 27, 2016

8. FOLLOW-UP RESPONSIBILITY: Chief, Diagnostic Imaging (114)

//s// Robert J. Fischer, MD Medical Center Director

Distribution: All services via Outlook

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