Changes to Examination

Reminder that any changes to an examination performed e.g. referral states left side but patient advises it’s actually the right side, must be documented appropriately.

If the information is provided when the patient comes in (or when the clerical staff confirm the scan/side being performed), then this needs to be documented on the referral and then the referral needs to be scanned into the patient record with that notation. Notes must also be made in the patient record. A note on the label to alert the technical staff is also required.

If this is not picked up at the front desk but when the patient is called for scanning, then the technical staff will need to make the notes on the referral and then scan or ask a clerical person to scan in the new referral. Notes need to be put on the old label so that this flags a change to the clerical staff, as well as a note in the patient record so that the reporting radiologist can see that this has all been confirmed. Technical staff must make the change to the study description and correct the exam prior to signing the patient out for reporting.

Please remember that not following simple communication steps can lead to medicolegal issues, so it is important to follow the steps to make sure everyone is aware of changes being made.