Medical Imaging & Diagnostic Tests in Chart Reviews

17 September 2012 / Chart Reviews / Comments Off on Medical Imaging & Diagnostic Tests in Chart Reviews

Medical imaging and diagnostic testing reports are of great interest. These reports are strictly objective.

Check the reason for the ordering of the test. This is usually a one to two sentence statement. Check any diagnostic imaging prior that is used for comparison in the conclusions. Again, do the findings support the diagnoses? Has the imaging ruled in or out any diagnoses, you may have in your mind as you read the record?

Remember, as you review medical imaging and diagnostic testing reports, are there any missing tests that would be critical for you to determine a diagnosis?

If you're reviewing, diagnostic tests, such as laboratory data, be sure to include normal range values. The reader may not know the normal ranges, or normal may vary from lab to lab.

I review laboratory results as "normal", "abnormal elevated", "abnormal low”, and "borderline high or low". If the laboratory value is going to play a critical role in my opinion, I will of course dictate the exact numeric value.

Search the chart for specific labs. For example, the hemoglobin A1c in diabetics when the case involves a nerve condition, i.e.carpal tunnel syndrome.

If such information is lacking in the medical record, be sure to comment on it and its significance in your discussion. The same is true with diagnostic tissue pathology. Example, if you're a dermatologist, confirmatory biopsies are critical in formulating a working diagnosis.

If a diagnosis needs to be made by tissue and is not included in the chart documents, be sure this is highlighted in your discussion.

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