April is Records and Information Management Month, a time to review your record keeping and storage practices to ensure that your office is compliant and organized. With so much medical technology to worry about — such as electronic medical records (EMR), billing, scheduling and other software tools — you may overlook that it is also time to update your ultrasound system. However, now is the best time to look at upgrading your practice's ultrasound technology.
Ultrasound Documentation Requirements
The American Institute of Ultrasound in Medicine outlined detailed parameters for best practices when documenting an ultrasound examination. All exams should include official documentation in the form of a permanent record and images of all areas defined in the report. Some essential elements of the interpreting physician's final report include:
- Patient information;
- Facility information;
- Date of scan;
- Image orientation;
- ICD code or clinical information;
- Techniques used;
- Measurements;
- Abnormalities or variations in normal size; and
- Diagnosis.
Images and reports must be stored with the patient's medical record and should be redundant to comply with billing requirements.
Streamlining Records and Information Management
The ultrasound system itself is meant to temporarily store the scans. So how can you streamline the process of getting the images to the record? A standalone ultrasound requires you to manually move and store the images in the appropriate location, but there is an easier way.
Most practices have some kind of cloud-based storage. With the vast amounts of data and images collected, on-site storage isn't feasible for most offices. Look for image management tools with HIPAA-compliant cloud storage options that coordinate seamlessly with other practice software.
Newer ultrasound systems offer connectivity with EMRs and cloud-based storage. Tools such as Tricefy can take the scans and reports directly from the ultrasound and automatically file them where they need to go. This reduces the manual effort required and aids in proper coding and billing. In addition, you can pull up images on any device with access and share them with consulting physicians safely and securely.
Ultrasound IT solutions such as Viewpoint 6 can also aid in records and information management. This tool enables you to store all your ultrasound images and reports in one location. You can create report templates to streamline the process for common gynecologic exams and easily retrieve reports and images when needed. Information management tools help simplify the process for your entire staff, reduce duplicate entries and minimize the need for paper records.
When you take stock of your practice's records management practices, remember to consider the capabilities of your ultrasound system. This is a rapidly growing tool for gynecology practices, and staying on top of your records is key to ensuring its profitability.
