The radiology report is an integral part of the medical record and must accurately convey the diagnosis and critical information about the patientâ€™s condition and needs. Radiology transcription companies play a crucial role in ensuring this. Dedicated reports of radiographic examinations need to have all the information necessary to justify diagnosis, course of illness, management, and treatment.
Today, physicians, insurers, and patients are demanding even greater consistency and organization in imaging reports. Diagnostic Imaging recently reported on this requirement for improved radiology reporting, which is driven by new payment systems and increasing quality reporting requirements of the Centers for Medicare & Medicaid Services (CMS). Moreover, as referring physicians are short on time, they need precise, informative reports that will help them take quick and accurate decisions about care.
Radiologists are facing many new challenges when it comes to ensuring high quality, imaging reports that promote the most informed patient care decisions. Such informative reports are critical for oncologists trying to diagnose if a patient has cancer or to determine the stage of a malignant tumor as well as about tumor location and metastasis.
Radiology transcription service companies provide affordable, quick and accurate transcripts of radiologistsâ€™ dictation, but today, there is the challenge meeting provider demands for electronic medical record integrated transcription. According to the report in Diagnostic Imaging, other key issues that radiology centers face when drafting reports are:
- Avoiding clinically significant errors
- Providing clinically meaningful and actionable information
- Answering all clinical questions
- Providing clarity in diagnoses
- Using new technologies to upgrade and update reports
In addition to stressing the need for succinct radiology reports with easily-identifiable information, the Centers for Medicare & Medicaid Services (CMS) requires that the reports sent to referring physicians should include three additional quality measures:
- Appropriate follow-up for incidental abdominal findings
- Appropriate follow-up for incidental thyroid nodules
- Utilization of CT dose-lowering techniques
According to CMS guidelines, radiologists must prioritize clinical considerations in the report as well as include patient history and notes.
In interactive reporting, one of the latest developments and preferred options in radiology, clinicians can use hyperlinks to go directly to imaging findings, measurement tables and graphs. A 2015 study by experts at the NIH Clinical Center Radiology and Imaging Sciences Department found that 85% of oncologists and 77% of radiologists prefer more interactive reporting, which is especially useful with picture archiving and communication systems (PACS). Multimedia enhanced radiology reporting (MERR) includes hyperlinks as well as other digital capabilities for easier information transfer. Recent studies also show that radiologists are experimenting with more standardized reporting.
Experts say that, in the future, it is likely the PACS system will be used as the EMR, providing a comprehensive platform for reporting, treatment options, and follow-up. As radiologists and physicians adapt to new protocols, they can rest assured that US based medical transcription companies will customizes their services to meet these changing requirements.