Preliminary and Final Reports
R. Eugene Zierler
In general terms, a vascular laboratory report is a document that describes a patient’s vascular testing encounter and provides a formal record of the facts surrounding a visit to the laboratory. Depending on the circumstances, a report may be verbal, handwritten, typed, computer generated and printed, or electronic. The primary purpose of the report is to convey diagnostic information that can be used by the referring physician for the benefit of the patient. Quality patient care depends on accurate and timely communication between the vascular laboratory and health care providers. Vascular laboratory reports can be considered as either preliminary or final.
PRELIMINARY REPORTS
A vascular laboratory report is considered preliminary until it is reviewed, edited, and signed by an interpreting physician. In contrast to most other diagnostic imaging specialties, the use of preliminary reports generated directly by the examining technologist or sonographer is extremely common in the vascular laboratory. In both the 2000 and 2005 surveys of Registered Vascular Technologists conducted by the American Registry for Diagnostic Medical Sonography (ARDMS), approximately 90% of the respondents stated that they provided preliminary reports to referring physicians, either verbally or in writing.1 Although this practice is so prevalent that it could be regarded as a standard in the United States, it remains controversial because the data in preliminary reports can be used to direct patient care without immediate input from an interpreting physician.
In order to carry out a complete and accurate examination, the technologist must rely on his or her knowledge of laboratory protocols and diagnostic criteria to document the key findings. This requires a certain level of interpretation, which forms the basis for the preliminary report. This report may be verbal, handwritten, or printed, but the preliminary status of the report must be clearly indicated so the referring health care provider will know that the results have not been reviewed by a physician. In many laboratories, a printed or electronic version of the preliminary report serves as a template for the final report. This typically includes the relevant patient information, indications for the test, a description of the test performed, a summary of the results, and a preliminary interpretation. The interpreting physician can then edit or add to this version to create the final report.
FINAL REPORTS
Whereas the preliminary and final versions of a vascular laboratory report may have much in common, the component that distinguishes a final from a preliminary report is an impression (or conclusion) that contains a physician’s interpretation of the data gathered during the study. This requires that the interpreting physician review the original images and physiologic information (depending on the specific test performed). In those unusual cases in which there is a substantial difference between the preliminary and final reports that could affect patient care, the laboratory must have a mechanism for bringing this to the attention of the referring physician. Similarly, when an examination reveals a potentially urgent or life-threatening condition, there must be a mechanism for communicating these findings to the appropriate health care providers in a timely fashion.
The incidental identification of nonvascular abnormalities is common in the vascular laboratory. Examples of such findings include thyroid lesions, renal masses, and Baker’s cysts. Unless the technologist and interpreting physician have expertise in nonvascular imaging, it is best not to render a detailed diagnosis in these cases, but rather to note the findings in the report and recommend additional imaging, as appropriate to the patient’s circumstances.
Elements of a Final Report
The Intersocietal Accreditation Commission (IAC) Vascular Testing has published Standards for all aspects of vascular laboratory practice, including interpretation and reporting (see Chapter 3).2 Table 2.1 lists the elements of a final report according to the IAC Standards. Although there is no single required format for final reports, they must include these basic elements. It is also important that interpretation and reporting be standardized within a particular laboratory. That is, all interpreting physicians in a laboratory must agree on and utilize consistent diagnostic criteria and a uniform report format. In general, diagnostic criteria
must be available for interpretation of B-mode images, Doppler spectral waveforms and velocities, color Doppler images, and any other imaging or physiologic testing modalities used.
must be available for interpretation of B-mode images, Doppler spectral waveforms and velocities, color Doppler images, and any other imaging or physiologic testing modalities used.
TABLE 2.1 ELEMENTS OF A FINAL VASCULAR LABORATORY REPORTa | ||
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The physician interpretation must be available within 2 working days of the examination, and the final signed report should be available within 4 working days. All records related to the examination, including the final report, must be retained in accordance with local, state, and federal guidelines for medical records—generally 5 to 7 years for adult patients.
Reporting Terminology
It is stating the obvious to advocate the use of standard medical nomenclature and clear language in vascular laboratory reports, but achieving this goal requires effort by both technologists and physicians. For example, the terminology for describing the venous system in the lower limbs has been problematic.3,4 Although many vascular laboratories use the historically correct term “superficial femoral vein” to describe the main deep vein of the thigh, experience has shown that some physicians are not aware that this is, in fact, a deep vein.5 Therefore, they may not consider acute thrombosis of this vein as a serious problem requiring immediate treatment. In order to avoid errors in patient management related to this misunderstanding, it is now recommended that the superficial femoral vein be referred to simply as the femoral vein, along with the common femoral and deep femoral veins.
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