{"id":14966,"date":"2022-01-25T20:10:09","date_gmt":"2022-01-25T20:10:09","guid":{"rendered":"https:\/\/www.medicalbillersandcoders.com\/blog\/?p=14966"},"modified":"2024-12-04T10:10:03","modified_gmt":"2024-12-04T10:10:03","slug":"providing-complete-clinical-information-to-radiologists","status":"publish","type":"post","link":"https:\/\/www.medicalbillersandcoders.com\/blog\/providing-complete-clinical-information-to-radiologists\/","title":{"rendered":"Providing Complete Clinical Information to Radiologists"},"content":{"rendered":"

It is not uncommon for radiologists to receive inadequate patient information that potentially compromises their diagnostic decision-making abilities and accuracy. The recent evidence-based study has shown that communication of clinical information to the radiologist, including patient complaints and indications for the imaging request, is required for a quality radiology interpretation process and for making recommendations. A 2021 study looked at more than 300 orders for MRI and CT exams and found that requisition indications were incomplete 81 percent of the time. Other studies noted that 72 percent of the time radiologists needed more clinical information than they received, and 87 percent felt that additional clinical information could change or modify the final report. It is important for radiologists to receive information that helps them arrive at interpretations that are consistent with clinical findings.<\/span><\/p>\n

The process for formulating radiological imaging interpretations can be improved by giving reading radiologists accurate clinical context at the time of order entry. Having ready access to clinical context helps radiologists eliminate assumptions and better positions them to apply their skills and expertise in rendering final interpretive reports. The types of pertinent clinical information to be provided by the ordering physician include the patient\u2019s surgical history, major medical conditions, relevant family history, social history (such as drugs, alcohol, or smoking), working diagnosis, signs and symptoms, and questions to be answered. Although there is no standardized protocol, the American College of Radiology mentions that such information can assist the reading radiologist to enhance the clinical relevance of the final report.<\/span><\/p>\n

Challenges for Radiologists<\/span><\/h2>\n

Many times, radiologists are unaware that a patient\u2019s clinical health information is missing when preparing to interpret a study and dictate a report. A challenge for radiologists can be searching for important information (for example, accessing an EHR<\/a> requires a system user sign-on, password, and training to maneuver to the patient clinical information) while balancing the pressure to keep pace with a large volume of assigned studies. Another challenge facing radiologists in interpreting studies for multiple hospitals or ambulatory centers, each with its unique EHR system. This results in the need to have access to and knowledge of multiple medical record systems. Radiologists are faced with a daily conundrum: Their desire to obtain the complete clinical context of the reason for an imaging study can interrupt the reading process due to the need to track down clinical information in an EHR. Depending on skill and experience levels, radiologists may voluntarily and inadvertently, assume the risk of a potentially inaccurate study interpretation by not taking the time to search for clinical health information not provided at the time of order entry.<\/span><\/p>\n

Guidelines for Complete Clinical Information\u00a0to Radiologists<\/span><\/h2>\n

Following guidelines can help you to avoid misinterpreted radiology studies that might happen due to lack of knowledge of a patient\u2019s clinical information:<\/span><\/p>\n