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Beginning
with applications received for the March 2000 deadline, all
reports received with the case studies must include both an
indication for the examination and a physician signature or
equivalent. These requirements were published in the 1997 revision
of the Essentials and Standards.
In
reviewing over 2000 applications for accreditation there has
been tremendous variability in the consistency and quality of
reports submitted with the case studies. Reports have ranged
from comprehensive type written documents containing all appropriate
components, to a simple one-line scribble (sometimes barely
legible) at the bottom of a work sheet. The Summer 1995 ICAVL
Newsletter article by Kenneth Rholl, MD, current ICAVL President,
describes the key components for every report, emphasizing the
fact that each report is a legal medical document and must meet
the current standards for medical documentation. (Read the article
The
Vascular Laboratory Report: Window To the Healthcare System.)
In spite of these efforts, the ICAVL continues to receive a
significant number of incomplete reports.
The
absence of a clinical indication(s) for performing a given examination
is one of the most frequent deficits. Most diagnostic medical
tests require evaluation of the results within the context of
the relevant patient problem. Noninvasive vascular tests are
often focused or expanded based upon the specific clinical presentation.
Failure to include indications in a report suggests such a focused
evaluation may not have been carried out. Furthermore, the specific
clinical questions leading to the performance of the test may
not have been addressed. In either case, without a complete
report including indications, healthcare personnel may not have
adequate information to understand the results and implications
of the examination.
Another
shortcoming of many reports submitted is the lack of a concise
relevant summary. In some cases the summary consists only of
a repetition of some of the findings (data) of the examination.
In other cases there may be no summary or final interpretation
at all. To enhance the clinician's understanding of the report
it is essential to provide a clear, concise interpretation as
a separate component of the report. In addition, it may be appropriate
to include an assessment of the relevance of the findings to
the clinical presentation.
Finally,
many reports are submitted without verification signatures.
Because vascular laboratory reports are legal records, every
report must be verified by the responsible physician in order
to be considered complete. In addition, a signed copy of the
report must be on file as proof that the review process was
completed. Increasingly, laboratories are utilizing electronic
records that may include an electronic signature. When electronic
signatures are used, the record must clearly indicate that electronic
verification of the report (electronic signature) has been completed.
The use of signature stamps is strongly discouraged. The use
of signature stamps provides the potential for inappropriate
use by personnel other than the physician whose signature appears
on the stamp.
In
the revised ICAVL Essentials and Standards for reporting
to be published in January 2000, the Board has added a requirement
that the signature (verification) be dated. Since the final
report may not be signed on the same day as the test was performed,
it is necessary to document the actual date of the signature
(verification). This policy reflects the growing trend across
the country to require dating of all signatures or authentications.
Increasingly, hospitals are adopting this policy in their bylaws
or regulations. Almost all electronic record systems automatically
attach a time/date stamp when a signature is added in the system.
The
January 2000 Essentials and Standards will list the following
required components for all reports:
1.
The date of the examination.
2.
The clinical indications leading to the performance of the
examination.
3.
An adequate description of the test performed. The description
will include the name of the examination and its integral
parts (e.g.: noninvasive arterial examination of the lower
extremities with segmental pressures and volume plethysmography).
4.
An overview of the results of the examination including pertinent
positive and negative findings. Where appropriate, this
will include localization and quantification of abnormal findings.
5.
Comparison with previous related studies when available.
6.
The reasons for limited examinations.
7.
A summary of the test findings.
8.
Signature and/or electronic verification.
9.
Date of signature and/or electronic verification.
Applications
submitted with reports that fail to meet the above reporting
requirements will result in the delay of accreditation for the
laboratory. The laboratory will be required to submit additional
documentation of reporting methods and additional case study
reports that adhere to the Essentials and Standards.
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