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RADD Report Writing Lecture > Midterm > Flashcards

Midterm Flashcards

1
Q

Role of report

A

Record findings
Documentation in med-legal circumstances
Provide a permanent record in case films lost or damaged
Provide communication with other health care professionals
Assist with indications, contra-indications, and prognosis for care

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2
Q

The global fee consists of

A

A technical component and a professional component

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3
Q

The technical fee is approximately

A

2/3 of the global fee

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4
Q

The professional comoponent is approximately

A

1/3 of the global fee

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5
Q

Time spent marking films and/or discussing the patient’s findings ___ part of the global fee

A

IS NOT

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6
Q

Technical component

A

Represents the production of the radiograph

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7
Q

The technical component includes

A

Equipment costs, time to position the patient, and time to create the image

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8
Q

The professional component is a full written typed reports

A

In the ABCS format as will be presented in this class

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9
Q

Check list type sheets ____ constitute a written report to satisfy the professional component

A

DO NOT

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10
Q

When using the global fee, there is a legal obligation to

A

Have a written report - otherwise, constitutes fraud

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11
Q

Failure to report an imaging study is analogous to

A

Performing a physical exam but not recording the findings

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12
Q

In order to meet requirement GA law states

A

You must make an appropriate diagnosis or at least a differential diagnosis

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13
Q

You are responsible for evaluating

A

The area of chief complaint

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14
Q

Local defense - NOT THE CASE

A

The idea that you will only be held to teh same standard as another DC in your locale

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15
Q

An action brought by the patient or when deceased the family against the practitioner for a crime of omission or comission - may result in punitive damages
Covered by malpractice insurance

A

MALPRACTICE

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16
Q

Any complaint to the board must be investigated
May or may not also have a malpractice claim
Often board complaints are not covered by malpractice insurance
Adverse decisions lead to licensure penalties to include revocation of the license

A

Board action

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17
Q

Responsibilities/liabilities when using an outside source

A

No opinion
Second opinion
Share the professional component

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18
Q

Things that alter liability even if films are sent out for review

A

Bad quality
Lack of opposing views
Failure to follow through on radiologist’s recommendations

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19
Q

Reasons to get a second opinion on x-ray

A 
Red flags
Complicated history or exam
Failure to respond to care as expected
Unexplained deterioration of the condition
Confirming the DC’s interpretation
Medicolegal support
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20
Q

Red flag indicators are often associated with

A

Significant underlying disease

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21
Q

Complicated history or exam

A

When patient aren’t like everybody else

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22
Q

Failure to respond to care as expected may point to

A

Misdiagnosis, or overlooked subtle finding

May lead to a decision on the next best step and the second opinion provider can assist even if not part of the report

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23
Q

Unexplained deterioration of the condition

A

Worsening of symptoms especially with care is often associated with significant underlying condiitons

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24
Q

Confirming the DC’s interpretation

A

When you have come to a diagnosis that isn’t an everyday finding a second opinion to confirm the interpretation is warranted

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25
Medicolegal support
In personal injury and worker’s compensation cases confirmation of findings is vital to teh outcome of the case
26
Digital transmission to send films out for review
Direct software to software connection | Transferring through the receiver’s VPN
27
Taking a digital photo and sending as an email
Is not really legal on both ends
28
Snail mail sending films
Purchase mailing envelopes thorugh film suppliers
29
Pertinent clinical information
Recent trauma (when, where, etc) Significant past history (tumor, metabolic disease, etc) Exam findings that aren’t like everybody else
30
You have a quesiton area on the film
Identify the finding with an arrow, circle, etc Or write a brief note noting your exact question like on the lateral film what is the transverse lucency through the posterior inferior body of L4
31
Comopnents of the radiology report
``` Biographical information History Body of report Conclusions/impressions Recommendations Signature ```
32
Biographical information
``` Patient name Patient age Patient number Date of exam Views taken ```
33
History
Optional Helpful when clinically significant Should be brief (inversion injury with pain at the base of the 5th metatarsal)
34
Body of report
``` Meat of the report Descriptions, NOT conclusions Precise descriptions Brief but complete Complete grammatically correct sentences ```
35
Body of report parts
A - alignment B - bone density C - cartilage S - soft tissue
36
Alignment
Not listings Pelvic inferiority, left or right curves, anterolisthesis, retrolisthesis, basilar invagination, dislocations/separations, valgus/varus, etc Be specific
37
Bone density
Hardest part
38
Cartilage
Changes around joint space | Changes to joint space
39
Anterior osteophytes are noted at C5/C6
Cartilage
40
Moderate disc narrowing is noted at C5/6
Cartilage
41
Anterior soft tissue markings are within normal limits
Soft tissues
42
Brief Phrases when possible (Degenerative disc disease C5/6)
Conclusions (impressions)
43
Some radiologists combine with conclusions | Clearly identify what and why
Recommendations
44
A universal compression fracture is noted at L3. Continued assessment with MRI or a combination of bone scan and lab work is necessary to differentiate osteoporosis, metastasis or multiple myeloma as the cause
Recommendations
45
Definitions for guidelines Acute Subacute Chronic
1-4 weeks 5-12 weeks Greater than 12 weeks
46
Adult patient acute neck injury x-rays indicated when any are present
``` Over 65 Paraesthesias in extremities Not a simple rear end collision Immediate cervical pain onset Presence of midline cervical tenderness Patient unable to actively turn head to 45 degrees in both directions ```
47
Acute neck injury x-rays NOT indicated when ALL of these are fulfilled
Simple rear end collision Delayed cervical pain onset Absence of midline cervical tenderness
48
X-rays ___ indicated in acute uncomplicated neck pain
ARE NOT
49
Uncomplicated means
Nontraumatic without underlying neurological findings or red flags
50
Acute neck pain is generally not due to
Conditions that can be seen on x-ray
51
X-rays are indicated in acute uncomplicated neck pain in certain circumstances
If prior to seeing you the patient has had treatment with no success take x-rays Consider x-ray or other tests in the absence of expected response to your care or if there is worsening of symptoms BE SURE TO RECOGNIZE RECURRENT PAIN VERSUS ACUTE PAIN
52
X-rays ____ indicated in nontraumatic neck pain AND arm pain or paraesthesia
ARE
53
X-rays ___ indicated in uncomplicated subacute and chronic neck pain with or without radicular symptoms
ARE | 4 weeks or longer
54
X-rays ___ indicated with complicated (red flags) neck pain
ARE
55
Patient less than 20 and over 50, particularly with S and S suggesting systemic disease
x-rays YES
56
Significant activity restriction greater than 4 weeks
YES x-rays
57
No resaponse to care after 4 weeks
X-rays YES
58
Intractable pain, constant or progressive S&S
X-rays YES
59
Neck rigidity in the sagittal plane in the absence of trauma
X-rays YES
60
Intractable pain - doesn’t go away, no position to releave the pain. Consistent or progressive signs and symptoms - hurts all the time no matter what
X-rays YES
61
2 things create dysphagia
OA and a tumor
62
Dysphagia
YES
63
Impaired consciousness
YES
64
Cranial n signs, pathological reflexes, long tract signs
YES
65
High risk lig laxity populations/suspected atlantoaxial instability
YES
66
Arm or leg pain with movement
YES
67
Cancer phobia
YES
68
Suspected neoplasm
YES
69
Suspected infection
YES
70
Suspected failed surgical fusion
YES
71
Progressive painful or structural deformity
YES
72
Elevated lab exam and positive S&S
YES
73
X-rays ____ indicated with recent (<2 weeks) acute T, L, or T/L trauma with ANY of these
ARE
74
Moderate to severe localized back pain
YES
75
Midline tenderness on palpation
Yes
76
Neurological deficits
Yes
77
MVA >50 mph
YES
78
Fall of 10 ft or more
YES
79
X-rays ARE NOT indicated with recent (<2 weeks) acute T, L, or T/L trauma with
Absence of pain Normal ROM Absence of neurological deficits
80
X-rays ____ indicated in acute patients with uncomplicated LBP, T pain
ARE NOT
81
Uncomplicated means
Nontraumatic No neurological deficits No red flags
82
X-rays ____ initially indicated with subacute or chronic LBP, T pain AND no previous treatment trial
ARE NOT
83
When no prior treatment has been attempted, a trial period of 4-6 weeks is suggested
Prior to radiographs
84
X-rays are indicated in the absence of expected treatment response or worsening after
4-6 weeks
85
X-rays ___ initally indicated with nontraumatic acute LBP AND sciatic (suspicion of disc herniation
ARE NOT
86
X-rays are not initially indicated with nontraumatic acute LBP and sciatic (suspicion of disc herniation) unless
``` Patient is >50 Or has progressive neurological deficits Or has unexpected response to care after 4-6 weeks Or worsens with care MRI would be of value ```
87
Signs of disc herniation - need 3 of 5 (consistent to same N level)
Primarily leg pain Leg pain confined to dermatome Neural stretch tests recreate or exacerbate the leg pain At least 2/4 neurologic findings consistent with dermatome - muscle weakness, decreased reflex, abnormal pinwheel, atrophy MR or CT correlating to dermatome
88
X-rays ____ indicated with suspected degenerative spondylolisthesis/lateral recess stenosis
ARE
89
Signs of degenerative spondylolisthesis in lumbar spine
Primarily scleratogenous leg pain (one or both legs) Comes and goes Often reduced by leanign forward or sitting down No neurologic findings Very common 4 F’s: fat, female, forty, L4
90
X-rays ____ indicated in complicated (red flag) thoracic and lumbar pain
ARE
91
S&S of systemic disease especially <20 or >50
Yes
92
Absence of expected treatment results or worsening avter 4-6 weeks
Yes
93
Significant activity restriction > 4 weeks
Yes
94
Unrelenting pain at rest
Yes
95
Constant or progressive S&S
Yes
96
Suspected inflammatory spondyloarthropathy
Yes
97
Suspected compression fracture
Yes
98
Suspected neoplasm
Yes
99
Suspected infection
Yes
100
Suspected failed surgical fusion
Yes
101
Progressive or painful structural deformity
Yes
102
Elevated lab and positive S&S
Yes
103
Criteria for inflammatory back pain
Morning stiffness for > 30 min Improvement of back pain with exercise but not resat Awakening in the second half of the night due to back pain Alternating buttock pain
104
Signs of suspected neoplasm
``` Considerable LBP >50 Hx of CA Unexplained weight loss Failure of conservative care Intractable pain ESR >50mm/hr Systemically unwell Lymphadenopathy ```
105
Special circumstances for x-ray
Pt unable to give a reliable Hx Crippling cancer phobia Need for immediate decision about career or athletic future or legal evaluation Hx of significant radiographic abnormalities elsewhere Hx of finding from outside study (abdomen, etc) that requires spine evaluation
106
X-rays ___ indicated with non painful non progressive adult scoliosis
ARE NOT
107
In a skeletally mature patient, scoliosis is
>10 degrees

RADD Report Writing Lecture (1 decks)

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