News: Reducing diagnostic errors possible through complete, accurate provider documentation

Poor documentation can flummox radiologists and systematic reporting must be a priority, Joseph Glaser, MD, a nuclear medicine physician at Radiologic Associates, PC in Middletown, New York, told HealthLeaders Media in an October 1, 2016 article.

"In communicating results, you not only have to report what's urgent and important but also secondary findings," says Glaser.

For instance, if a patient comes in for a chest x-ray with a presumed diagnosis of pneumonia, the report must not only describe whether there are clear lungs, but also the observation of a broken rib. "We may find a surprise that can change patient management," he says.

And how these findings are relayed to the doctor is equally important. While new technology has helped tremendously, he says, there are still times when a simple phone call is the most effective way to ensure timely and clear communication. This can also help on the incoming end as well.

"While some incoming documentation is concise and clearly states what is being evaluated, there are also occasions when incoming documentation contains a great deal of additional material—often automatically generated—that may make it difficult for the physician to find what they need," he says.

He encourages imaging physicians to learn how referring doctors receive information and incorporate those preferences into their reporting. "Doctors on both ends can suffer from information overload, so it's better to know what findings they want about certain conditions," he says.

Editor’s note: This brief is an excerpt from an article originally published by HealthLeaders Media. Click here to read the full article.