Diagnostic Reports

Whenever a patient undergoes medical imaging there is a wealth of information that must be added to their case file. Complete and accurate diagnostic reports are essential for physicians to be able to make the best decisions about future patient care and to spot problems early so as to know when further examinations and investigations are needed. Diagnostic reports come from all areas of medical specialty, including radiology, obstetrics, cardiology, psychiatry, and surgery so it is vital that reports are clear, well formatted according to appropriate guidelines, and are as complete as possible so as to facilitate an easier diagnostic process and improve patient care.

Examples of the kinds of things requiring diagnostic reports include x-ray, ultrasound, computerized tomography (CT), magnetic resonance imaging (MRI), and nuclear medicine, among other tests. Each has its own transcription guidelines and each enters into the Radiology Information System (RIS) and the Picture Archival Communication System (PACS) so that referring physicians are able to instantly access the patient’s results following the procedure. Referring physicians are not, however, specialists in every aspect of radiology and rely on precise diagnostic reports to aid them in their diagnoses.

Even minor errors on diagnostic reports can adversely influence diagnosis by confusing physicians as to what the images actually show. Providing such diagnostic reports promptly whilst maintaining accuracy and including sufficient information can be a challenge; doing this well is, however, extremely important in helping physicians make fast and effective choices for patient care. Quality diagnostic imaging is a remarkable tool for improving the prognosis of patients but it is only as good as the radiologists and physicians using such a resource and only works when the diagnostic report produced after such imaging is complete, accurate, precise and quickly disseminated through the right channels.

Clearly, a major goal for radiologists and those producing diagnostic reports is to find ways to streamline the diagnostic report process and reduce errors in reporting. This is vital for every radiology department so as to improve their value to patients and physicians and help enhance revenue and reputation. increasingly, radiologists are realizing the potential application of medical speech-to-text voice recognition technology when compiling reports but there are still issues relating to formatting and compliance. Whether the report is for pain management, mammography screening, bone mineral density tracking or other purpose, a clear and quickly available diagnostic report gets patients on the right track faster.

Turnaround time from image acquisition to a full and accurate diagnostic report can be just a day when processes are finely tuned. Patients do not, and should not have to wait for weeks while dictated notes are sent to transcribers and then returned for review before being sent manually to a physician. The use of voice recognition software embedded in the RIS saves time and has the further advantages of producing clear, functional reports that automatically adhere to formatting guidelines and compliance requirements. A diagnostic report can easily be completed using CaseReader embedded with M*Modal Fluency voice recognition technology with key images included in the report for the physician’s convenience. Radiologists can feel more secure in the accuracy of their reports and can, quite substantially, cut the time it takes to produce such reports. Storing diagnostic reports on the cloud means that the radiologist and colleagues, the referring physicians and other relevant medical personnel can all access the patient’s medical information whenever necessary.

Implementing a system to separate out the clinical information from the procedural information also makes it easier to find the details relevant to each query whilst keeping the report uncluttered and organized. The technologist will provide details on the scanning process itself, such as the dose amount, specialized equipment used, any problems with the procedure and so forth, while clinical information can be entered courtesy of RIS, PACS and other sources. This diagnostic report system also includes ICD/CPT codes for quick use by radiologists, as well as allowing for extra information to be added should the radiologist have specific comments that need recording. Using smart links connecting images to their origin makes for a streamlined response when assessing such diagnostic reports. Such a customizable structure for the production of superior quality diagnostic reports makes it extremely useful across a variety of clinics and applications.