Harbor:Entering Prelim Radiology Read
- ED Entering Radiology Prelim Reads
- Monday 7a through Friday 4p (in-house radiology): if you discharge a patient before the final XR read is completed, please enter your interpretation into the notes section of synapse
- Eg, Chappell – neg/radius fx/RLL pneumonia – x66902
- Do NOT use the “wet read” feature in FirstNet as no one will ever see it
- If there is a minor discrepancy, radiology will use the message pool that is checked by the CCC NP
- If there is a critical discrepancy, radiology will call the Green attending
- Friday 4p – Monday 7a (StatRad): if you discharge a patient before the final XR read is completed, place the patient on the CCC list; in the results/symptom check section, write “final XR read” and summarize your interpretation of the film (so the CCC NP will know what you thought it was vs the final read without having to dig through the entire chart)
- Monday 7a through Friday 4p (in-house radiology): if you discharge a patient before the final XR read is completed, please enter your interpretation into the notes section of synapse
- Please enter a prelim read on ALL unread imaging (XR, US, CT without prelim or final read) so radiology knows to call if we missed something
- In Synapse "notes" section write the following and "add new note"
- "ED PRELIM [Your findings] [Your Name] [Your Spectra link Number]"
- I.e., ED PRELIM - Fracture R distal radius. Peterson 23202
- "ED PRELIM [Your findings] [Your Name] [Your Spectra link Number]"
- In Synapse "notes" section write the following and "add new note"
- The 7am Triage Resident will review any discrepancies daily.
- Go to Synapse --> DHS Enterprise Synapse --> Conferences --> Critical Findings --> ED Discrepancy
- Open "preliminary" studies to view the discrepancy notes from the radiologist
- If unclear of significance, ask an attending
- If acting on discrepancy, please document a free-text "Imaging Follow-up" note and include the study type and date
- I.e., "CXR on 8/15/17" demonstrated 6mm pulm nodule; messaged PCP to ensure f/up
- I.e., "Head CT from 7/31/18 referred for follow-up on 8/1/18. Small subdural hematoma seen. Patient called and agrees to return to ED today."
- If no action is needed, place a note in Orchid: "Radiology discrepancy reviewed - no follow-up required"
- When finished with f/up, change the status in synapse by right-clicking on "preliminary" --> "shortcut status" --> "complete"
- Go to Synapse --> DHS Enterprise Synapse --> Conferences --> Critical Findings --> ED Discrepancy
2/25/19 - Peterson/Chappell