Harbor:Main: Difference between revisions
Line 8: Line 8:
* The 7am Triage Resident will review any discrepancies daily.   
* The 7am Triage Resident will review any discrepancies daily.   
** Go to Synapse --> DHS Enterprise Synapse --> Conferences --> Critical Findings --> ED Discrepancy
** Go to Synapse --> DHS Enterprise Synapse --> Conferences --> Critical Findings --> ED Discrepancy
** Review
*** Open "preliminary" studies to view the discrepancy notes from the radiologist
1. When you open synapse, look in the folder marked "ED Discrepancy" (DHS Enterprise => conferences => critical findings => ED discrepancy)
*** If unclear of significance, ask an attending
2. When you open this folder, you'll find a list of studies marked either "preliminary", or "completed".
*** If acting on discrepancy, please document a free-text "Imaging Follow-up" note and include the study type and date
3. Any study labeled “preliminary" needs to be opened, to see what the radiologist wanted to communicate to us. Radiologists will be notifying us of important discrepancies between our preliminary reading and their final reading.
**** I.e., "CXR on 8/15/17" demonstrated 6mm pulm nodule; messaged PCP to ensure f/up
4. If you are not clear if any follow-up is needed - talk to the Senior ED Resident or Attending ED Provider.
*** When finished with f/up, change the status in synapse by right-clicking on "preliminary" --> "shortcut status" --> "complete"
5. Any action you take should be documented in Cerner in a Provider Note titled :"Imaging Follow-up". Be sure to mention they study type and date (eg "CXR on 8/15/17") If a note has already been started, and you are doing further follow-up on the same case - just add an addendum to the previous case.
*** If no action is needed, comment in the synapse notes section "Case reviewed - No follow-up required" and put your name.  
6. When any action that needs to be taken is completed, change the status of the study from "preliminary" to "completed".  This lets the next person know that they don't need to do anything for that particular case.  To change the status:
a. Right-click on the study whose status you want to change.
b. Select "status shortcut".
c. Select "completed".
7. Not all cases will need follow-up. If no action is taken - document in synapse in the notes section "Case reviewed - No follow-up required" and put your name. This way we know the case wasn't just marked "completed" by mistake.
8. IF the radiologist determines the finding is critical, they will call one of the ED spectra phones (either attending or senior resident, to immediately inform them of the finding




Line 39: Line 33:




3/25/19 - Peterson
2/25/19 - Peterson


==General Administrative==
==General Administrative==

Revision as of 00:15, 1 March 2019

This is the main page for Harbor-UCLA emergency department; See Pediatric ED for the main Harbor pediatric page.

Message of the Moment

  • Radiology Discrepancy Process
    • 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"
      • "ED PRELIM [Your findings] [Your Name] [Your Spectra link Number]"
      • I.e., ED PRELIM - Fracture R distal radius. Peterson 23202
  • 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
      • When finished with f/up, change the status in synapse by right-clicking on "preliminary" --> "shortcut status" --> "complete"
      • If no action is needed, comment in the synapse notes section "Case reviewed - No follow-up required" and put your name.


Sample Note when follow-up is needed: This goes in CERNER

"Imaging Follow-up

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. Discussed with M. Peterson"


Sample Note when no follow-up required: This goes in SYNAPSE Notes section for the exact study:

"Case reviewed - No follow-up required. Discussed with M. Peterson. Jane Doe, NP"

Note than in SYNAPSE no need to state type or date of study as you will be entering comments directly on that study. You DO need to put your name as your name is not automatically added in synapse.


2/25/19 - Peterson

General Administrative

Managing your Patient

General

Tests & Orders

Consults

Finding Things

Procedures

Special patient types

Patient Disposition

Discharge

Admission, OBS, & CORE

Other Disposition

Documentation

Disaster & Surge

Resident Education

See Also

Retrieved from "https://www.wikem.org/w/index.php?title=Harbor:Main&oldid=207640"