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Report Writing > midterm > Flashcards

midterm Flashcards

1
Q

What are the roles of report writing

A
  • record of findings
  • medicolegal documentation
  • permanent record
  • inter- professional communication
  • provides important indications and contraindications
  • assisting in auditing radiographic quality
  • database for retrospective research and data collection
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2
Q

the radiology report is part of the _____

A
  • medical report/ record

reports are the result of a radiographic test

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3
Q

The C’s of a report

A
  • clear
  • correct
  • confidence
  • concise
  • complete
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4
Q

name the most common reason for malpractice suits against chiropractors

A
  • failure to communicate results clearly and effectively

- failure to diagnose

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5
Q

what is in the preliminary report information

A
  • letterhead information of the report writer
  • date of the report
  • name and address of the referring clinician
  • patint information
  • radiographic exams performed (dates and locations)
  • clinical information
  • chief complaint
  • key clinical findings
  • reason for the study- differential dx
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6
Q

what is In the report

A
  • technical factors- kVp, mA,FFD
  • radiologic findings - ABC
  • Conclusion
  • recommendations ( additional imaging
  • Signature and qualifications
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7
Q

Film Interpretation

A
  • turn off lights to all unused box spaces
  • hot light exam
  • cover- up emxam - cover up 1/2 of film
  • film tilt - detect scratches
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8
Q

Optimum environments

A
  • suboptimal viewing conditions
  • time allocation
  • demographic details
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9
Q

How to have clarity of content and report structure

A
  • concise reporting
  • correct english
  • avoid jargon
  • avoid abbreviations
  • quantifying terminology
  • standardized format
  • measurements
  • proofreading
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10
Q

When to get a second opinion radiology review

A
  • complicating history - red flags
  • abnormal clinical findings
  • failure to respond to therapy
  • unexplained deterioration of the condition
  • confirming the practicionar’s interoperation
  • establish a dx
  • improving interpratation skill
  • interpreting equivocal findings
  • use of complex multi modality imaging
  • medicolegal support
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11
Q
  • Describe how the reporting flow chart should be in order
A
  1. orientation and placement of films
  2. patient identification
  3. systematic review
  4. ABCs
  5. Conclusion/ impression and recommendations
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12
Q

ABCs means what?

A
  • A= alignment
  • B= Bone
  • C= cartilage
  • S = soft tissue
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13
Q

What is recorded in the alignment part of the report

A
  • evaluate spinal curve
  • evaluate scoliosis
  • evaluate leg length inequality
  • evaluate alignment of joints
  • use of lines of measurements
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14
Q

What is recorded in the Bone part of the report

A
  • evaluate bone density
  • evaluate cortical and cancellous bone for fractures and osseous destruction
  • evaluate size, shape and configuration of all osseous structures
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15
Q

What is recorded in the Cartilage in the part of the report

A
  • cartilage is not visualized on x- rays
  • this category is about the joints
  • evaluate width of joint cavity between opposing articular surfaces
    • widening of joints
    • loss of mint space
    • osteophytes
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16
Q

What is recorded in the soft tissue report

A
  • overall thickness and density of the soft tissues ( retotracheal air spaces)
  • evaluate skin , fat pads , deposits, tendons, organs , blood vessels , ligaments
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17
Q

What goes under Impressions of the report

A
  • point by point summary of the most important radiological findings ( conclusion)
  • categorize the pathological process ( CATBITES)
    C- congenital
    A- arthritis
    T- trauma
    B- blood
    I- infection
    T- tumor
    E- endocrine
    S- soft tissue
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18
Q

What goes into the recommendations report

A
  • plan of actions based on impression
  • recommend further studies like MRI
  • provide specific clinical or therapeutic advice, like chiropractic adjustments
  • suggestions to improve radiographic quality
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19
Q

what is required at the end of all radiology reports

A
  • signature and credentials
20
Q

list some general guidelines

A
  • all reports should be typed , not written
  • be brief
  • use complete sentences
  • use present tense for what is seen on the film
  • quantify all measurements
  • proof read the report
21
Q

With acute neck injury name some that may be x-ray indicated

A
  • over 65
  • paraesthesias in extremities
  • not a simple rear end collision
  • immediate cervical pain onset
  • presence of milline cervical tenderness
  • patient unable to actively turn to 45 degrees in both direction
22
Q

in acute neck injury x-rays are not indicate when all of the following CCSR criteria is met

A
  • simple rear and collision
  • delayed cervical pain onset
  • absence of midline cervical tenderness
23
Q

T/F

x-rays are indicated in acute uncomplicated neck pain

A

fasle

uncomplicated means non traumatic without underlying neurological findings or red flags

24
Q

X- rays are indicated with complicated ( red flags) neck pain

A
  • patient ( 20 and > 50 , particularly with S&S suggesting systemic disease
  • significant activity restriction > 4 weeks
  • intractablle pain, constant or progressive
  • neck rigidty in the sagital plain in the absence of trauma
  • Dysphagia
  • impaired consciousness
  • cranial n signs
  • high risk log laxity
  • arm or leg pain with movement
25
Q

Signs of disc herniation ( need 3 out of 5 )

A
  1. primarily leg pain
  2. leg pain confined to dermatome
  3. neural stretch tests recreate or exacerbate the leg pain
  4. at least 2 of 4 neurologic findings consistent with dermatome
    - MR or CT correlating to dermatome
26
Q

Signs of degenerative spondylolisthesis in the lumbar spine

A
  • primarily scleratogenous leg pain
  • comes and goes
  • often reduced by leaning forward or sitting down
  • no nerologic findings
  • very common
  • 4 F’s : Fat, female, forty and Lfour
27
Q

Criteria for inflammatory Back Pain

A
  • morning stiffness for > 30 minutes
  • improvement of back pain with exercise but not rest
  • awakening in the second half of the night due to back pain
  • alternating in the second half of the night due to back pain
  • alternating buttock pain
28
Q

What is a global fee

A
  • record findings
  • documentation in me- 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
29
Q

Technical component

A
  • represents the productions of the radiograph

- includes equipment costs, time to position the patient, and time to create the image

30
Q

Professional component

A
  • is a full written typed report in the ABCs format a

-

31
Q

Failure to have a written report when using the global fee constitutes what

A

fraud

32
Q

what is referred as a local defense

A

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

33
Q

Describe what malpractice is

A
  • an action brought by the patient against the practitioner for a crime of omission or commission
  • may result in punitive damage but is not a board issue
  • covered by malpractice insurance
34
Q

Describe what is board action

A
  • any complaint to the board MUST be invesitaged
  • may or may not also have a malpractice claim
  • often board complaints are not covered by malpractice insurance
  • adverse decisions lead to liscensue penalties to include revocation of license
35
Q

what would go under body of a chest x-ray report

A
  • inspiratoory effort (10 ICS normal) this is optional
  • lung fields : infiltrate, mass, abnormal markings, cavitations
  • Diaphragm : height, shape, calcification
  • any pleural fluid or thickening
  • size of heart ( should be less than 50% of thorax)
36
Q

list the accessory views for the cervical spine

A
  • flexion/extension - looking for motion, ligament laxity, aid integrity
  • obliques- looking at pedicles, pillars, IVF
37
Q

name the accessory views for the lumbar spine

A
  • obliques- pars,lamina, soft tissue
    • Post obliques: anterior structures move farther from spine and posterior structures move closer to the spine versus the AP
  • Ant obliques: posterior structures move farther from spine and antterior structures move closer to the spine versus the AP
38
Q

name the accessory views of the knee

A

-Tunnel
See intercondylar notch
-Sunrise
See patella femoral joint

39
Q

name the accessory views for the shoulder

A

Accessory
Baby Arm
Helps with HADD, more of a true lateral

Y View
Good for dislocations and scapular assessment

40
Q

which view is helpful with scaphoid fracture assessment and to assess integrity of certain ligaments

A

Ulnar deviation of the wrist

41
Q

reporting soft tissues findings should include

A
  • organ enlaargement or displacement
  • displacement of normal structures like the tracheal air shadow
  • abnormal accumulation of bowel gas
  • abnormal soft tissue calcifications
  • soft tissue swelling
  • masses
  • displacement or blurring of fascial planes
  • foreign bodies
42
Q

Impressions should include:

A
  • a conclusion
  • use diagnostic terminology
  • label the conditions described
  • list in order of severity
43
Q

Recommendations should include

A
  • (optinional)
  • give specific flow up procedure
    additional x rays
    advanced imaging
    lab evaluation
    refer
    explain why
44
Q

Signs of suspected Neoplasm

A 
- considerable Low back pain > 50 
HX of Ca 
- unexplained weight loss 
- failure of conservative care 
- intractable pain 
- ESR > 50 
- systemically unwell 
- Lymphadenopathy
45
Q

Special Circumstance for X- ray

A
  • pt unable to give a relaible HX
  • Crippling cancer phobia
  • need for immediate decision about career or athletic future or legal evaluation
  • Hx of sig radiographic abnormalities elsewhere
  • Hx of finding from outside story that requires spine evaluation
46
Q

T/F
in a skeletally mature patient scoliosis is > 10 degrees with non painful , non progressive , it is indicated to take X- rays

A

false

Report Writing (2 decks)

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