PATIENT HISTORY Getting it right!. Background A good patient history is the key to appropriate image interpretation. Think of Waldo- you are more likely.

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PATIENT HISTORY Getting it right!

Background A good patient history is the key to appropriate image interpretation. Think of Waldo- you are more likely to make a relevant finding if you know what you are looking for! In addition, inadequate histories can lead to payment denials or delays. Your billing staff will send rejected claims to you with the request to provide additional signs and symptoms. So, why not get it right the first time?

Body part Symptomatic Acuity Clinical info: To interpret studies appropriately, we would like to know -What happened -Symptoms, signs -Working diagnoses, DD, rule outs -Relevant past medical history Billing info: To get reimbursed we need -Indication of acuity -Indication of a specific body part -Symptoms, signs

Examples: CT brain HistoryAcuityBody partSymptomatic Trauma??? How about these? 1.45 y.o. F, s/p assault 2.Aneurysm clipping

Examples: CT brain HistoryAcuityBody partSymptomatic AMS

Examples: CT brain HistoryAcuityBody partSymptomatic TIA? ?

Examples: CT brain HistoryAcuityBody partSymptomatic Stroke? ?

Examples: CT cervical spine HistoryAcuityBody partSymptomatic Pain ?

Examples: CT brain HistoryAcuityBody partSymptomatic Headache, vomiting

Examples: CT brain HistoryAcuityBody partSymptomatic 70 year old male with dementia who was found down at NH s/p fall. Pt is alert, confused. Reports L hip pain. C - collar on. Hematoma to forehead, abrasion to nose.