|
The IAC Standards
and Guidelines |
3.1A Provisions
exist for the generation and retention of examination records of all studies
performed which will permit evaluation of annual procedure volumes.
3.1.1A Essential
portions of all examinations must be documented and retained on appropriate
media. This may include hard copy (printed, photographic and/or digital media)
cine images and graphics, and, if applicable, printed documentation of
measurements.
3.1.2A All
examination recordings including images and a signed, dated final report, as
outlined in Sections 3.1A and 3.2A, must be maintained in an accessible fashion
for a minimum of the applicable legal requirements for medical record-keeping.
3.2A MRI examinations
are interpreted and reported by the Medical Director or by a member of the medical
staff of the MRI facility.
Comment: The report represents the final interpretation of the MRI examination
and is part of the patient’s legal medical record. As such, the report
must be in the form of a document that is retrievable and/or reproducible for
review by health care personnel. In general, the report must contain sufficient
information so that any health care professional has access to adequate
information regarding the indications for the examination, the type of
examination performed and the results of the diagnostic study.
(See Guidelines below for further
recommendations.)
3.2.1A All
of the MRI examination images must be reviewed by the interpreting member of
the medical staff or the Medical Director.
3.2.2A Final
interpretations must be verified and, either manually or electronically, signed
by the Medical Director or a member of the medical staff of the facility.
3.2.3A A
permanent record of the interpretation must be made and retained in accordance
with applicable standards for medical records.
3.2.4A The
report must accurately reflect the content and results of the study. The
contents of the report must include, but are not limited to:
3.2.4.1A Date
of the examination
3.2.4.2A Clinical
indications leading to the performance of the examination
3.2.4.3A An
adequate description of the test performed including the:
i. patient
ID or name;
ii. date
of birth;
iii. name
of the examination;
(See Guidelines below for further recommendations.)
3.2.4.4A An
overview of the results of the examination including pertinent positive and
negative findings. Where appropriate, this must include localization and
quantification of abnormal findings.
3.2.4.5A The
reasons for limited examinations
3.2.4.6A A
summary of the test findings
3.2.4.7A Comparison
with previous related studies, where available
3.2.4.8A The final report must be
reviewed, signed and dated manually or reviewed, signed and dated digitally by the interpreting physician.
i. If
the report is manually signed by the interpreting physician, the date of the
signature must also be manually recorded on the report with the signature.
ii. If the report is electronically signed and dated by the interpreting physician, the electronic signature and electronic date of signature must be clearly labeled that it is an electronic signature, and an electronic date of signature.
iii. If the report is signed digitally,
the signatures must be password protected with sign off only by an
interpreting physician. The signature must have a valid digital
date/time stamp.
• The report must be in a form that cannot be modified or altered after it has been digitally signed.
3.2.4.9A The brand and volume of IV contrast used in the examination.
3.2.5A If
preliminary reports are issued, their preliminary nature must be clearly
indicated. Verified final reports must be provided within a reasonable interval
after posting of preliminary results. A mechanism for communicating any
significant changes must be defined for those situations in which the final
interpretation differs substantially from the preliminary report.
3.2.6A A
mechanism must be defined whereby the results of examinations which demonstrate
urgent or life-threatening findings are communicated to the appropriate health
care professionals immediately.
3.2.7A The
physician’s final interpretation (in the form of paper, digital storage
or voice system) must be available within two working days of the examination
date and the final, verified, signed report sent to the referring physician
within four working days, unless awaiting additional clinical information.
3.2A
Experienced technologist should be able to reproduce the exam based on the
description provided.
Identification of the technologist performing the MRI examination should be
documented.
3.2.5.2A an
adequate description of the test performed should include:
-pulsed sequences (imaging contrast);
-imaging planes used in the performance of
the examination