Clinical history on imaging requisitions (formerly triggering questions)

Stefanie Lee stefanieylee at GMAIL.COM
Fri May 3 13:53:02 UTC 2013


Indeed, this (focusing on history/physical and not the diagnosis to be
ruled out) is the approach and mindset I try to adopt whenever
possible -
mostly on call when phoned about all requests, and are able to listen to
the patient history being presented to us.

Otherwise, I think current technology is a limiting factor in communication
between radiologists and referring physicians. Ideally, history and
physical would already be in the electronic medical record, and be
available automatically upon viewing a study, but there are barriers to
integration (#2 in this synopsis of an article by Nagy et al. in this
month's AJR):
http://www.auntminnie.com/index.aspx?sec=sup&sub=ris&pag=dis&ItemID=103303&wf=1

If not automated, I think it would be difficult to have busy clinicians
provide detailed information routinely on requests - it is common to see
requests reading simply "r/o -----." Other motivations for focusing on the
diagnosis may be ensuring correct protocolling as well as seeing the
pathology of concern explicitly addressed in the report.

Some referrers provide more detailed information, but may at times be
illegible or
paraphrased by clerks - in the academic setting, we are used to digging
through the EMR for lab values and clinic notes... Some practices also ask
technologists to take a basic history and include the information with the
study.



On 2 May 2013 16:12, robert bell <rmsbell at esedona.net> wrote:

> This brings up the point of the history and physical being given to the
> radiologist, without any differential.
>
> I do not see this done too often - why not?
>
> It seems it could help.
>
> Rob Bell
>







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