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Wiki Dictation documentation question

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suela923@aol.com

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Hi all,

I have a doctor that often dictates statements such as:

Contrast material was injected through the patient's percutaneous biliary drain. Multiple spot films were obtained. With contrast injection there is contrast material tracking along the tube and exiting through the puncture site. I would like to see him state cholangiogram but is it actually necessary?

A needle was successfully advanced into the lower pole left renal collecting system. Contrast material was injected. Under flurorscopy and with the aid of spot films an AccuStick system was brought into the intrarenal collecting system. Moderate dilation to the intrarenal collecting system is observed on the left side. Does the doctor have to actually state the words antegrade pyelogram or does contrast injection/spot films suffice?

Thanks,
Sue
 
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