Harbor:Main: Difference between revisions
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*Radiology Discrepancy Process
*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
** 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"
** In Synapse "notes" section write the following and "add new note"
*** "ED PRELIM [Your findings] [Your Name] [Your Spectra link Number]"  
*** "ED PRELIM [Your findings] [Your Name] [Your Spectra link Number]"  
*** I.e., ED PRELIM - Fracture R distal radius. Peterson 23202
*** I.e., ED PRELIM - Fracture R distal radius. Peterson 23202
* 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
*** Open "preliminary" studies to view the discrepancy notes from the radiologist
*** Open "preliminary" studies to view the discrepancy notes from the radiologist
*** If unclear of significance, ask an attending
**** 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
**** 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., "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"
*** 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.




Revision as of 00:47, 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 new note"
      • "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
          • 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"


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

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