jhanmer83
Networker
I have a compliance question regarding ultrasound documentation and where the interpretations get documented. Currently at the clinic I work at the ultrasound techs document the technical data on the ultrasound reports with their findings, but the providers document their impressions/interpretations in amongst the office visit notes. It was brought to my attention recently that the providers have no access to be able to alter or change anything that the ultrasound techs document in their part of the ultrasound report and they can't add their impression directly to the report due to how the system is set up. I know that all imaging requires a separate report and my thinking is the impression is an element of that separate report and must be separate from other clinical documentation, especially for instances when a patient only allows the release of their imaging studies and not their office visit notes. Is the way they're documenting acceptable, or should they be doing a separate note linked to the ultrasound encounter with their impression/interpretation?