The Medical Record: What mistakes radiologists can make !

As we enter Year 2013, the medical record (including notes, transcribed reports and the electronic medical record) become even more important for optimal medical care.

Radiologists must report their imaging findings contemporaneously for accurate reporting.  Any corrections, alterations, addenda or late entries are acceptable.  They must be so labeled, dated, timed and the radiologist author clearly spelled out. 

Radiologists are held to the same standard of care as their clinical colleagues.  Nothing substitutes for a phone call to a clinical colleague that a report is being revised and why. I have never had a clinician object to a brief phone call explaining new observations that might help his/her clinical care of a patient.

Happy Holidays to all!!!