The
final report represents the key link between the vascular laboratory
and the health care system. It provides information to health
care personnel to be used for the purpose of both directing
further diagnostic work up and treatment of a patient. As such,
a complete, accurate and timely report is vital to providing
optimal health care to that patient. Yet, in reviewing applications
for accreditation, the final report is frequently the most deficient
part of noninvasive vascular examinations. Many contain only
an impression such as " moderate to severe peripheral vascular
disease" without an adequate description and localization
of the disease. Others lack any clinical information as to why
the examination was performed. Still others are allowed to languish
on a desk indefinitely, thereby providing no significant information
to anyone who may become involved in the patient’s health
care.
In
1997, the ICAVL incorporated into its Essentials and Standards,
guidelines for the generation of final reports. The goal of
these guidelines was not to force all accredited laboratories
to produce identical "canned" reports, but rather
to insure that a complete interpretation of the results of the
examination is readily available to anyone in the health care
community who may be involved in the care of that patient. At
its most recent meeting, the Board of Directors of the ICAVL
discussed the Essentials and Standards as they relate to the
final report, reiterating the importance of these documents.
Following are the key points from this discussion:
1.
Format. There are many acceptable formats to the final report,
however, all physicians interpreting in the laboratory must
agree on a single standardized report format and utilize uniform
diagnostic criteria. Reports may be handwritten, typed, or electronically
stored, as long as the guidelines for reporting are met. It
is recognized that the storage of examination data and reports
is rapidly changing with a trend toward electronic storage media.
Voice dictation could conceivably be utilized as a format for
final reports as long as it is accessible to all personnel involved
in the care of the patient, though few systems currently utilize
this for long-term storage. The key elements of the final report
are content and availability.
2.
Content. The necessary content of the final report as outlined
in the Essentials and Standards, Part I, Section 4.1
include the type of study; the date the study was performed;
the clinical indication for the study; and overview of the study
including pertinent positive and negative findings; comparison
with prior studies, if available; the reasons for a limited
examination, if applicable; and a summary of the findings with
a clearly delineated impression. When appropriate, the clinical
implications of the study should be included.
3.
Physician Interpretation. The final report represents an
interpretation of the results of the study by a qualified physician.
It is the responsibility of the interpreting physician to collate
the clinical information with the data provided by the technical
study to arrive at an appropriate interpretation. The Essentials
and Standards require that all examination data (including
measurements, images and recordings) be reviewed by the interpreting
physician. In general, a signature applied to a technologist
worksheet would not be considered a final report unless it contained
all of the necessary content and an appropriate interpretation.
4.
Physician Verification. All final reports must be verified
by a member of the medical staff, preferably by the interpreting
physician. Given the various formats in which a final report
may exist, verification may be a traditional signature, or in
the case of computerized reporting/transcription systems, an
electronic signature. The verification date should also be included.
The use of signature stamps is acceptable only if the physician
whose name appears on the stamp uses it.
5.
Timeliness. The Essentials and Standards require
"completion of the final report within two working days
of the examination." The Board understands that some additional
time may be necessary for transcription, correction and verification
and allows additional time for final verification as long as
some form of the final report is available for the purpose of
clinical management in the interim. This may take the form of
a physician written, typed or electronic report marked as "uncorrected",
"not reviewed", "unverified" or "preliminary".
Alternatively, availability of the physician voice dictation
on a system equipped to allow access to outside health care
personnel will suffice. The critical element of this report
is that it be a physician-generated interpretation and that
it is available to other health care personnel as soon as possible
following the completion of the examination. Again, a technologist
worksheet or a preliminary report generated by a technologist
is not considered an adequate form of final report. For additional
information regarding the legal aspects of preliminary reports,
please read The
Growing Flap Over Preliminary Interpretations on the Society
Of Vascular Technology website.
The
goal of ICAVL accreditation is to promote optimal patient care
through the delivery of quality noninvasive vascular testing.
As the report is the critical link between the technical portion
of the examination and the subsequent delivery of health care,
the importance of the final report cannot be overstated. By
following the general guidelines listed above, consistent, meaningful
reports will be generated and excellence in health care promoted.
John
Gocke, MD, MPH, RVT
represents the Society For Vascular Medicine and Biology on
the ICAVL Board Of Directors, where he has served as President.
Dr. Gocke is the Medical Director of the LaGrange Memorial Vascular
Laboratory.
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