RIS_CGD290_02.09.10e_Radiology_Reporting_Correct_Usage_1.1

Radiology Reporting Correct Usage

Course Guide

(Rowthorne)

Contents

Introduction & Purpose

Audience

TRAINING SET-UP

EXERCISE ONE: CORRECT USAGE

1.USING THE REPORT INFO LIST

2.HOW TO CORRECTLY DICTATE AND SAVE A REPORT

3.HOW TO CORRECTLY AMEND AND SAVE A REPORT

4.HOW TO QUIT WITHOUT REPORTING

5.HOW TO MARK A REPORT AS IN PROGRESS

6.MANUAL LOGOUT VERSUS AUTO LOGOUT

EXERCISE TWO: WORKING WITH LOCKED DICTATIONS

EXERCISE THREE: REVIEWING / EDITING EXISTING RECORDS

7.IDENTIFYING A COMPLETED / IN PROGRESS DICTATION

8.ADDING ADDENDUM DICTATIONS

9.LISTENING TO DICTATIONS OR REVIEWING REGISTRAR REPORTS

10.ADDING TO AN EXISTING DICTATION (I.E. AMENDMENTS TO REGISTRAR DICTATIONS)

11.REVIEWING PACS IMAGES IN MULTIPLE LOCATIONS

12.VERIFYING REPORTS

Introduction & Purpose

The purpose of this document is to clarify ‘Radiology Reporting Correct Usage’ for dictating clinicians. This guide does not replace basic training on use of Digital Dictation and Report Info List but has been developed as a companion training document to ensure that existing CRIS users (i.e. sites who have been live for some time) can ensure that their Radiologists and Reporting clinicians are utilising the system correctly.

OVERVIEW OF THE DICTATION & REPORT LOCKING ISSUES

CRIS Dictation and Report Locking features have been specifically designed to stop multiple users accessing / dictation the same record, and to allow users to highlight that they are currently working on a record to improve electronic workflow processes. If a dictation / report is currently loaded by another users a locked icon appears next to the dictation icon in the events screen.

This is an extremely useful feature if a reporting clinician is distracted for a short period of time as it enables them to return to their work at the point they left it and complete the dictation / report whilst the system is left in a secure state in the intervening period.

However it has been established that some reporting clinicians do not ‘Save or Release’ Patient Records / Events correctly prior to vacating a terminal for an extended period of time.Thisis not correct system usage.

If a record is not ‘Saved or Released’ prior to manually logging out of the CRIS system, or the reporting clinician fails to log out entirely invoking auto logout the record remains locked to that user. The lock will be removed once the user re-opens the record and completes the dictation, or if another user overrides the lock assuming they feel it appropriate to do so.

Unfortunately, because some users do not subsequently return to their terminals, or revisit the patient record they had previously locked,records are then being left in a transitional state where they are classed as dictated, but not completed.

Consequently they do not appear on the [Report Info List] for dictating / reporting unless the ‘Show Dictations’ flag is ticked, or the [Dictation List] for typing because they have not been completed.

This could resultin Patient Record / Events being overlooked for reporting due to incorrect system usage.

In addition to ensuring the correct working practice and XR configuration is in place, HSS have also developed a new Statistical Report Template ‘RIS_STAT262 DICTATION LOCKS & UNTYPED DICTATIONS’ which is designed to identify any affected records to enable them to be typed/corrected as required. This should be run as a routine ‘Housekeeping Exercise’ by RIS System Managers or Clerical Managers. You should refer to RIS_CRIB279_Statistical_Reports_Templates.doc for full details.

WORKING PRACTICE / CORRECT SYSTEM USAGE

Trusts should ensure that all reporting clinicians are fully aware of correct system usage which is outlined via this document. It is however essential that in addition to the system being used as recommended, standard Trust ‘Report Turnaround Monitoring’ is observed and facilitated via the use of CRIS error checking utilities.

ERROR CHECKING UTILITIES

In addition to ensuring the correct working practice is in place, HSS have also developed a new Statistical Report Template ‘RIS_STAT262 DICTATION LOCKS & UNTYPED DICTATIONS’ which is designed to identify any affected records to enable them to be typed/corrected as required.

This should be run as a routine ‘Housekeeping Exercise’ by RIS System Managers or Clerical Managers.

Audience

This document is aimed primarily at RIS and PACS System Managers, CRIS Trainers and Applications Specialists at Accenture, CSC and HSS in order to retrain and advise relevant staff on correct system usage and best practice, thereby negating the potential for any clinical incidents which could occur as a result of misuse.

TRAINING SET-UP

Create Two USERID’S:RADIOLOGIST1 and RADIOLOGIST2 (LOCK THESE AFTER USAGE)

EXERCISE ONE & THREE EXAMPLE PATIENTS

Create 3 Example Patients as follows:

PATIENT, ONE 01/01/80OPD, XCHES

PATIENT, TWO 01/01/80OPD, CSKUH

PATIENT, THREE 01/01/80OPD, FBAEN

PATIENT, FOUR01/01/80OPD, XCHES, XABDO

Dictate, Type and Verify the XCHES, XABDO for Patient Four which will be used to demonstrate Addendum Dictation.

EXERCISE TWODUMMY PATIENT

Create Two Dummy/Test Patients using USERID: ARAD2

Darth, Vader (or Test Patient)01/01/1948INPATIENT, CSKUH, Urgent 5 Request

Luke, Skywalker (or Test Patient) 01/01/1978OPD, MSKUH

Login as ARAD2 and go into each record and dictate, then logout halfway through the dictation to permanently lock the record.

EXERCISE ONE: CORRECT USAGE

Login as USERID: RADIOLOGIST1 and select DICTATION mode.

  1. USING THE REPORT INFO LIST(MAKE REFERENCE TO CRIS CRIB SHEET - RIS_CRIB284 REPORT INFO LIST)

Explain [Report Info Screen], mentioning ‘Show Selected’, ‘Show Unallocated’ and how to create and use ‘Filter profiles’. Highlight ‘Order by Urgency and ‘Urgency Colour Coding’ via [Options] and mention ‘Auto Select’ but do not activate.

  1. HOW TO CORRECTLY DICTATE AND SAVE A REPORT((MAKE REFERENCE TO CRIS CRIB SHEET - RIS_CRIB274 DIGITAL DICTATION )

Load ‘1st Patient Record’ and demonstrate the correct way to report and save a Dictation.

  1. HOW TO CORRECTLY AMEND AND SAVE A REPORT((MAKE REFERENCE TO CRIS CRIB SHEET - RIS_CRIB274 DIGITAL DICTATION)

Reload ‘1st Patient Record’ and demonstrate the correct way to amend/insert extra information using the new PASSIVE MODE functionality and save the Dictation using [EOL] or [Finished].

Also mention the use of 2nd Radiologist Field, and that this will remain set as Radiologist One (Person Logged In) and Two (2nd Radiologist)until removed.

  1. HOW TO QUIT WITHOUT REPORTING((MAKE REFERENCE TO CRIS CRIB SHEET - RIS_CRIB274 DIGITAL DICTATION)

Load ‘2nd Patient Record’ and demonstrate how to ‘Quit without Reporting’ by pressing [F5] or the ‘Clear Icon’ in the event that you do not wish to report this patient. Explain that this is essential in order to ensure that the record does not remain locked by you and is still available via the Reporting Worklists for other clinicians to dictate.

If you have already begun ‘recording’ you will be presented with an additional error message upon clearing as follows:

You should therefore click [OK] in order to release the report to other clinicians for reporting.

  1. HOW TO MARK A REPORT AS IN PROGRESS(MAKE REFERENCE TO CRIS CRIB SHEET - RIS_CRIB274 DIGITAL DICTATION)

Load ‘3rdPatient Record’ and demonstrate how to mark a record as ‘Priority 1’ to indicate that this is in progress.Reload the ‘2nd Patient Record’ and demonstrate the correct way to complete the report and reset to ‘Priority 2’ before saving. Explain that if the reporting clinician chooses to mark a report in progress rather than completing the report first as recommend, it is their responsibility to ensure that they retrieve and complete the report as soon as possible after the fact.

  1. MANUAL LOGOUT VERSUS AUTO LOGOUT

If you wish to leave your CRIS workstation at any time, it is essential that you save your work then logout before doing so via the use of [Alt – L] or the Pad lock icon.

Failure to do not only contravenes NHS IT Policies, Data Protection and Clinical Guidelines but also means you will lose your unsaved dictation, and lock the Event/Patient record you were viewing when the CRIS terminal auto logs out after a period of inactivity.

The patient record you were viewing will then remain locked until you personally log back in to release the Event/Patient Record.Correctly used the locking feature is designed to ensure that the same patient record is not inadvertently reported by multiple-clinicians but is rendered useless if clinicians do not correctly exit or mark dictations as in progress before leaving a terminal.

Please note: Failure to follow the correct Reporting Procedures demonstrated above could result in a clinical incident in the event that an Event/Patient record is overlooked due to incorrect system usage.

  1. EXERCISE TWO: WORKING WITH LOCKED DICTATIONS(MAKE REFERENCE TO CRIS CRIB SHEET - RIS_CRIB274 DIGITAL DICTATION)

Explain the purpose of ‘Locking Icons’ and ‘Passive Mode’ and demonstrate the error message which is displayed if an Event/Patient Record is locked by another user using Darth Vader.

This message is specifically designed to ensure that anyone attempting to load an Event/Patient record which has been LOCKED by another user is clearly ‘warned’ of current ‘Owners’ Name, the Time they began reporting, and their location.

Consequently except in exceptional circumstancesthe answer to this question should be [No] unless you are sure that the person who has locked the report has done so in error, and this Event/Patient Record remains outstanding.

However, if you do you choose [Yes] an additional message will appear to advise this report has already been started, and to formally confirm that you really want to replace the dictation with you own. In most cases you should click [Cancel] unless you are entirely sure that you wish to overwrite/remove the report started by another clinician and replace it with your ownby clicking [OK].

EXERCISE THREE: REVIEWING / EDITING EXISTING RECORDS

  1. IDENTIFYING A COMPLETED / IN PROGRESS DICTATION

Highlight that it is very important to ensure that you do not load Events/Patient Records that are marked with a ‘Dictated’ speaker icon via the [Report Info List] or any other lists as this indicates that they have already been dictated.

Reload the ‘1st Patient Record’ to illustrate that whenever you begin reporting you should always ensure that there is no ‘voiceprint’ at the bottom of the report as this indicates that recording/dictation has already taken place.

If this is the case you should immediately press [F5] to clear the screen. Additionally reports marked as ‘Priority 1’ normally indicate that the report is in progress and will be completed by the clinician as soon as possible.

The only exceptions to this rule are if the Event/Patient Record has already been typed and verified and it is your intention to add an Addendum to the record, or you wish to amend a Registrar report.

  1. ADDING ADDENDUM DICTATIONS(MAKE REFERENCE TO CRIS CRIB SHEET - RIS_CRIB274 DIGITAL DICTATION)

Load ‘4th Patient Record’ to demonstrate how to add an ‘Addendum Dictation’ to an existing typed and verified Event/Patient record.They should however be very careful to ensure that the report has been typed and verified before proceeding.

  1. LISTENING TO DICTATIONSOR REVIEWING REGISTRAR REPORTS(MAKE REFERENCE TO CRIS CRIB SHEET - RIS_CRIB274 DIGITAL DICTATION)

Login as USERID: RADIOLOGIST2

Explain how tolisten to existing dictations or review registrar reportsvia the Dictation screen using the new PASSIVE MODE.

  1. ADDING TO AN EXISTING DICTATION (I.E. AMENDMENTS TO REGISTRAR DICTATIONS)

Explain that if having listened to a Registrar Dictation they wish to make amendments, or add additional information they should click on the [Edit] function buttonand entertheir details via the ‘2nd Radiologist’ field.

TO ADD A DICTATION TO THE EXISTING DICTATION –Using ‘1st Patient Record’ enter a new dictation, leaving the Registrars original dictation for reference/comparison.First click [Insert] either on-screen or via the Speechmike, then click at the beginning of the ‘voiceprint’ next to the [Clear Marks] and recordthe new dictation. To save the changes click [Finished] or press [EOL] on the Speechmike.

TO OVERWRITE THE EXISTING DICTATION –Using ‘2nd Patient Record’ overwrite/remove the original registrar dictation, by clicking at the beginning of the ‘voiceprint’ next to the [Clear Marks] and recording a new dictation. To save the changes click [Finished] or press [EOL] on the Speechmike.

***IMPORTANT PLEASE NOTE***

DICTATION AND TRANSCRIPTION OF REPORTS

In both of the above scenarios the reviewing consultant should begin their dictation by advising the secretary that this dictation is an addition to the original dictation, and provide the name of the Registrar.

This is both to prevent any confusion during transcription, and to ensure that secretary manually updates the ‘Tape Details’ as required. The secretary should thereforechange the ‘1st Reported By’ field from the reviewing consultant code to the correct registrar code, and confirm or enter the Reviewing Consultant’s code via the ‘2nd Reported By’ field. This is due to the fact that if a provisional dictation is amended the ‘1st Reported By’ field is updated with the last person to save the report - i.e. the registrar code is overwritten with the reviewing consultants code.

VERIFYING / AUTHORISING REPORTS

A report can only be formally authorised / verified (for printing and electronic transmission of results via PACS / PAS / OCS) by a Verifying Clinician who is not marked as a TRAINEE, or is a TRAINEE who has been assigned the security setting to verify reports.

If a user marked as a TRAINEE attempts to verify / authorise a report, the report will remain flagged as ‘Unchecked’ until it is authorised by a Senior Clinician (i.e. a user who is NOT marked as a TRAINEE via the Radiologist Set-up Table).

Additionally, any Report with a 1st and 2nd ‘Reported By’ (i.e. Two Reporting Clinicians) can only be verified / authorised by a Senior Clinician (Non TRAINEE).

Failure to observe the above points will mean that affected reports may not reappear on subsequent Verifying lists, will not be included in Batch Printing, and finally will not be sent to 3rd Party results system such as PACS / PAS / OCS etc.

  1. REVIEWING PACS IMAGES IN MULTIPLE LOCATIONS

Occasionally, a reporting clinician may wish to discuss an Event/Patient Record and associated images with a 3rd party who will review the records (i.e. a colleague or senior consultant) whilst the original reporting clinician also has the Event/Patient Record loaded.

The new PASSIVE MODE via the Dictation screen allows both clinicians to view the Event/Patient Record and associated images (The reporting Clinician in Active Mode, and the reviewing Clinician in Passive Mode). Consequently, once the reviewing clinician has provided their opinion they should press [F5] to clear the record, and enable the original reporting clinician to complete the dictation/report.

Conclude by highlighting the importance of clearing the record via the use of [F5] once completed.

  1. VERIFYING REPORTS(MAKE REFERENCE TO CRIS CRIB SHEET - RIS_CRIB277 BATCH VERIFYING)

You should conclude the session by emphasising the following points concerning Batch Verifying:

VERIFYING / AUTHORISING REPORTS

This option will enable a report to be authorised / verified (for printing and electronic transmission of results via PACS / PAS / OCS) so long as the verifying clinician is not marked as a TRAINEE, or is a TRAINEE who has been assigned the security setting to Verify reports.

Please note: Any Report with a 1st and 2nd ‘Reported By’ (i.e. including a 2nd Radiologist) can only be verified / authorised by a Senior Clinician (i.e. a user who is NOT marked as a TRAINEE via the Radiologist Set-up Table).

If a user who is marked as a TRAINEE attempts to verify / authorise a report with a 1st and 2nd Reported by, the report will remain flagged as ‘Unchecked’ until it is authorised by a Senior Clinician (Non TRAINEE). Failure to observe this point will mean that affected reports will notreappear on subsequent Verifying lists, will notbe included in Batch Printing, and finally will not be sent to 3rd Party results system such as PACS / PAS / OCS etc.

SKIPPING REPORTS

To skip the currently loaded report and move to the next outstanding report without making any changes. The report will then re-appear for resolution during your next verifying session.

SUSPENDED REPORTS

This option is designed to enable you to suspend a report in order to make changes later, or to be able to re-check any other information and complete the report during your next verifying session.

UNCHECKED REPORTS

This is used to allocate a report to another person for verification. This will allocate an ‘Unchecked’ report tothe selected person. Press [F4] and select from the list to allocate the ‘Unchecked’ report to a colleague’s[Batch Verify] List.

Please note: You should only assign unchecked reports to Senior Clinicians, as any reporting clinician flagged as a TRAINEE is prohibited from Verifying Unchecked Reports. Failure to observe this point will mean that affected reports will notreappear on subsequent Verifying lists, will notbe included in Batch Printing, and finally will not be sent to 3rd Party results system such as PACS / PAS / OCS etc.

UNVERIFYING REPORTS DURING BATCH VERIFY

It is possible to unverify one or more reports during a batch-verifying session. This facility is available via the Unverified screen, by right-clicking the relevant patient record. Having done this an unverify menu will appear for each section of the report (summary/clinical history and each exam associated with the attendance), and you should therefore simply click each element which you wish to unverify, then you can proceed back to the report itself to edit further.

Please note:Great Care must be taken when doing this, if the Interfaces have no pause, the original report may have already gone over to the PACS and any other 3rd Party System. If this is the case, adding an addendum may be a safer option.

Please note: It is only possible to unverify reports during the current Batch Verifying session, consequently if you wish to unverify after quitting the current Batch Verifying session you will need to contact your system manager.

QUIT (DURING A SESSION)

Should you wish to quit out of batch verifying at any time press [F5] to clear the current patient record from the screen, then click [Done] on the Batch Verify screen.

Last Updated: DC 01/09/2009 Healthcare Software Systems – Commercial in Confidence Page 1 of 10