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Evaluation
of the final report is considered by many to be the most important
part of the accreditation process because it demonstrates the
overall quality of the nuclear medicine facility in question.
Upon reviewing information submitted for accreditation, ICANL
Board members and application reviewers identify a wide variety
of reporting deficiencies. Report deficiencies remain the most
frequent issue for delay in accreditation. Commonly seen deficient
nuclear medicine reports range from those lacking final impressions
or stress details, to those void of a specific purpose for which
the test is being performed or a description of the radiopharmaceutical
and its dose. Regardless of the specific deficiency, poor quality
final reports provide little or no value to the referring physician
and, in many unfortunate cases, lead to inappropriate clinical
management decisions.
As
stated by Frans J. Th. Wackers, MD, PhD, ICANL President, in
his book Nuclear Cardiology, The Basics: "The referring
physician is entitled to a clear conclusion: normal or abnormal,
and if abnormal, how severely abnormal. The report may indicate,
when appropriate, whether the risk for future cardiac events
is low, moderate, or high. Certain imaging findings may have
different clinical implications depending on the clinical context
and results of stress testing. These nuances should be conveyed
in an optimal report. If there were technical limitations to
the study, they need to be stated and their impact on the final
interpretation indicated."
The
American Society of Nuclear Cardiology's Consensus Statement
entitled "Reporting of Radionuclide Myocardial Perfusion
Imaging Studies" is available online at www.asnc.org/resources/reporting_rmp_imaging.pdf.
Written to serve as a standard for all nuclear cardiology laboratories,
this document, published in August 2003, identifies the critical
factors involved in effective reporting.
The
ICANL Standards include specific guidelines for final
reports. The goal of these guidelines is not to force all accredited
laboratories to produce identical, "canned" reports,
but rather to ensure that a complete interpretation of the results
of the examination is readily available to anyone in the health
care community who may be involved in the care of the patient.
The
necessary content of the final report, as outlined in the Standards,
Part II, Section 6.3, includes, but is not limited to:
A.
Patient's name, gender, age and identification number, if
applicable
B.
Requesting health care provider's name
C.
Date of the examination
D.
Date of the report
E.
Clinical indications leading to the performance of the examination
F.
An adequate description of the procedure performed. The description
must include the type of the examination(s). It must also
include the type, amount and route of administration of any
radioactive or non-radioactive material administered. The
type of stress, if applicable, must be described.
G.
An overview of the results of the examination including pertinent
positive and negative findings. Where appropriate, this will
include localization and quantification of abnormal findings,
including stress test findings, if applicable.
H.
The reasons for limited examinations and/or deviations from
standard protocols, if applicable
I.
An overall succinct impression
J.
Any need for additional studies based on the interpretation
of the nuclear cardiology procedures
K.
Identification and manual or electronic signature of responsible
physician
In
some cases, the content and format of the report itself are
acceptable; however, issues with timeliness of the report's
dissemination are to blame for resulting suboptimal patient
care. Acceptable timeframes for reporting are addressed in the
Standards, Part II, Section 6.1.1 as follows:
6.1.1
All diagnostic procedures must be reviewed promptly after
the study is completed as appropriate for the risk of clinical
significant results. Reports of examinations should be:
A.
Interpreted and prepared within one working day.
B.
Signed by the interpreting physician within two working days
after completion of the examination and forwarded to the referring
health care provider.
Visit
the ICANL website at www.icanl.org/icanl/apply/sampledocs.htm
to download templates for an Exercise Spect Report, an ERNA
report, and a Vasodilator/Adrenergic Stress Spect Myocardial
Perfusion Imaging Report.
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