copy and pasted radiology reports

rosie.mckellips@northmemorial.com

Wondering what other hospitals are doing with copy and pasted radiology reports in notes and taking diagnoses from them. We are trying to do education to say that you need to query the provider for clinical significance and the provider should note it in their progress notes narrative and/or assessment and plan what the full circle of care was meaning treatment and plan to show clinical significance.
Thoughts??

cari.merlina@uchealth.org

Our docs have started doing this to save time. I have mixed reviews from our coding staff as to whether they will code from it. ED docs are also pulling in GCS and again we just don't know what to do with it.

Best Regards,

Cari Merlina RN, BSN
Clinical Documentation Improvement Specialist
Revenue Cycle
Yampa Valley Medical Center
p.970.871.2425
f.970.875.2796
Cari.merlina@yvmc.org

evanspx@sutterhealth.org

One really can't code directly from Radiology Reports...suggest a query. Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not reported unless an authorized provider indicates their clinical significance.

****************************************************************************************************************************************8

Request for Clarification or Confirmation Of Radiology Findings


Dear Physician/PA/NP: __________________________________________________________________ or other responsible provider:
For accurate coding and severity-of-illness compilation, this query is directed to you. When responding to this query, please exercise your independent professional judgment. The fact that a question is asked does not imply that any particular answer is desired or expected.

Abnormal findings (laboratory, x-ray, pathologic, and other diagnostic results) are not reported unless an authorized provider indicates their clinical significance.

The Radiologist has identified on ________________ (DATE) in the __________________________ (TYPE OF EXAM)

The Diagnosis: _____________________________



Please validate this diagnosis.

CDI Specialist/Coder: _________________________________ Date:_____________ Time: _______________


Physician/PA/NP Response:

CONFIRMATION:

0 I concur with the Radiologist Findings
0 I do not concur with the Radiologist Findings
0 Cannot be determined

CLARIFICATION of findings: Please document any SPECIFIC diagnosis or pathology associated with these Radiology findings.

0 Diagnosis/Pathology: ______________________________________________

0 No clinical significance

0 Cannot be determined




Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421



evanspx@sutterhealth.org

evanspx@sutterhealth.org

Modify as you wish, if you wish.

PE

Paul Evans, RHIA, CCS, CCS-P, CCDS
 
Manager, Regional Clinical Documentation
Sutter West Bay
633 Folsom St., 7th Floor, Office 7-044
San Francisco, CA 94107
Cell:  415.412.9421



evanspx@sutterhealth.org

rosie.mckellips@northmemorial.com

Thank you, Paul.