Sunday, May 29, 2011

WRITTEN INTERPRETATION AND REPORT DOCUMENTATION

Based on the increased number of provider questions regarding written interpretation and report of diagnostic X-rays, Medicare expects the separate and distinct report (may be on separate paper or within the body of the patient's record) for the interpretations to follow the American College of Radiology (ACR) guidelines and include a minimum of the following:

* The name of the patient and other identification such as birth date and Social Security number.
* The name of referring physician, if any.
* The name or type of examination performed.
* The date on which the X-ray was performed.
* The name of the interpreting physician.
* Authentication of non-handwritten note (i.e., legible initials, legible signature, electronic signature, etc.).
* The body of the report:
o Procedures and materials.
o Findings.
o Limitations.
o Clinical issues.
o Comparative data, if indicated.

* The diagnosis:
o A prescribing diagnosis should be provided when possible.
o A differential diagnosis should be provided when appropriate.

1 comment:

  1. For security reasons the patient should have render any valid documentation for their own protection. This list is much appreciated. Thanks for the effort on sharing this write-up.

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