Radiologist-referrer Consults' Documentation Found Lacking

In cases with informal consultations between referrers and radiologists, the documentation lacks significant detail, researchers found.

This article was originally published on July 20, 2017, on the Association of Clinical Documentation Improvement Specialists.

Researchers at NYU Langone found that many informal consultations between referrers and radiologists were captured incompletely or inadequately in the electronic health record (EHR), according to Health Imaging.

To conduct the study, the researchers entered either the term “radiology” or “radiologist” in combination with terms such as “second opinion,” “overread,” “discussed with,” and others.

From the search results, they then constructed a representative cohort of 300 notes describing informal consultation between a referring physician and a diagnostic radiologist, according to Health Imaging.

Some of their findings include:

• Only 18.7% of the physicians’ notes indicated the name of the consulted radiologist
   
• Of the consultations with a local radiologist regarding a specific prior examination, 33.9% resulted in a new finding, a change in the severity of a previous finding, or a change in the management recommendation
   
• Of the consultations with a change from the initial report, 24.6% were documented by the radiologist in an addendum; 92.9% of the addenda agreed with the referring physicians’ notes

The potential implications for patient care linked to these findings led the researchers to recommend radiology practices instill policies to correct such documentation deficiencies in a paper published in the American Journal of Roentgenology.

“Although we do not assert that additional documentation is necessarily warranted when a radiologist simply agrees with one’s own earlier interpretation, documentation is required for any communication that may alter patient management,” the researchers write.

Of course, CDI professionals already know this conundrum. When two providers’ documentation disagrees, a query has to be sent. The researchers, in their paper, recommend developing policies to avoid this confusion in the first place, thus eliminating a need for more queries.

Of course, addenda offer only one solution, the researchers point out. In fact, they write that sometimes an addendum is not an appropriate solution, giving as an example consults that are not related to a specific imaging exam.

“Direct documentation within the patient’s record in the EMR may be one possible solution for such instances, such as through a radiologist’s consultation note stored within the imaging section of the EMR,” the authors write.

The paper also suggests that radiology practices establish standard procedures for handling documentation of a change in interpretation compared with a report initially provided by a different radiologist.

“Although these may present challenging or uncomfortable situations,” they write, “identifying solutions is valuable not only for radiologists’ own practice but also for patient care.”

Editor’s note: To read the complete paper published in the American Journal of Roentgenology, click here. To read Health Imaging’s coverage of the findings, click here.