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Documentation Guidelines for Ultrasound Examination

Documentation Guidelines for Ultrasound Examination

Accurate and complete documentation and communication by all members of the diagnostic ultrasound healthcare team are essential for high-quality patient care. It’s essential to have a permanent record of the ultrasound examination and its interpretation. Images of all relevant areas defined in the particular parameter, both normal and abnormal, should be recorded and stored in a retrievable format (preferred source: electronic). Retention of the ultrasound images and reports must be consistent with clinical needs and relevant legal and payer requirements.

Communication between the interpreting provider and the referring provider should be in a manner that minimizes any mistakes or potential errors. In certain cases, the referring, ordering, performing, and interpreting physician might be the same person; even in such cases, everything should be documented properly. All communication should be performed complying with relevant regulations and preserving patient confidentiality. The physicians are urged to refer to the applicable practice parameter for each type of ultrasound examination, as it may contain additional documentation requirements.

Requirements for the Ultrasound Examination

Ultrasound examinations should be recorded in a manner that will allow subsequent review for adequacy for diagnostic purposes. Although for some applications still-frame images may suffice, archiving of dynamic imaging (video/cine loop) may be required or preferred for some types of examinations, always seeing relevant practice parameters. For digitally stored static and/or dynamic images, the information contained in metadata should be readable/displayable during the review of the images. For analog records, identifiers should be contained on the image. If you are using a worksheet then documentation on the worksheet should contain, at least, the patient’s name and other identifying information, the date and time of the ultrasound examination, and the name of the person(s) who performed the examination and completed the worksheet.

Final Report Provided by the Interpreting Provider

The definitive documentation of the study is a signed final report of the ultrasound findings which should be included in the patient’s medical record. The responsibility of the interpreting provider is to make the report available to the ordering provider who has a responsibility to review the final report. The imaging facility should archive a retrievable copy of the final report as part of the patient’s medical record and ensure that the requesting provider has access to the final report or a copy of the report. The way you archive and communicate the reports and images should comply with local, state, and federal regulations.

Reporting of Non-routine Results

In certain circumstances, such as cases in which immediate patient treatment is necessary or in keeping with expectations of a particular practice environment, a preliminary report of the ultrasound results may be provided to the patient’s referring healthcare provider(s) before the generation of the final report. This includes practice environments and situations in which the referring, performing, and interpreting provider are the same person, such as in point-of-care ultrasound in which a preliminary impression is documented during the course of care.

The preliminary report must contain the specific ultrasound examination performed, the date and time of such ultrasound examination, the patient’s information, requesting provider’s information, the interpreting provider’s contact information, and pertinent clinical information. The preliminary report contains limited information and may not contain all of the results that will subsequently be found in the final report.

Documentation and Reporting of Ultrasound-Guided Procedures

Documentation of the informed consent communication between the provider and the patient concerning the procedure including risks, benefits, and alternatives should be part of the medical record and performed in compliance with local standards and any applicable state and federal law. A signed final report of the ultrasound-guided procedure should be included in the patient’s medical record and is the definitive documentation of the procedure. The final report should be generated, signed, and dated by the performing provider/interpreting physician in accordance with state and federal requirements. Final reports should be available within 24 hours of completion of the examination or, for nonemergency cases, by the next business day.

We referred ‘American Institute of Ultrasound in Medicine (AIUM) Practice Parameter for Documentation of an Ultrasound Examination’ article to discuss documentation guidelines for an ultrasound examination. Legion Healthcare Solutions is a leading medical billing company providing complete billing and coding services. We can help you in receiving timely and accurate reimbursements for delivered services. Legion Healthcare Solutions is having extensive experience working with eClincialWorks (ECW), Lytech, Medisoft, AdvancedMD, Kareo, Office Ally, and all major medical billing software. To know more pain management billing services, contact us at 727-475-1834 or email us at info@legionhealthcaresolutions.com

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