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Anesthesia Coding Alert

Guideline Help:

ACR Lists Components of Formal Reports

Published on Sun Jan 01, 2006

Documentation would get an 'A,' but doctors might not go for it

If your group is struggling to determine what constitutes a -formal radiological report,- check out the American College of Radiology's (ACR) Standard of Communication at www.acr.org. The ACR's guidelines state the report should include four main components:

- Demographics (facility, patient and physician names, date, and type of exam, etc.)
- Relevant clinical information and ICD-9 codes as available
- Body of report (procedure, findings, potential limitations, clinical issues, comparisons)
- The physician's impression (conclusion or diagnosis). 
 
Using standardized template reports is acceptable if the template follows these guidelines.
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