AFTER THE BIOPSY: DICTATING REPORTS
1. All procedure reports should have the macro “time-out” in the dictation at the end of the “Consent” section (see Ambrose’s macros on PowerScribe to get the “time-out” macro).
2. Please dictate the correct needle TYPE, GAUGE and LENGTH into every report. Please review the page "Tools of the CT/Bx Trade"
3. Please also dictate the number of samples and where they were sent (e.g. “One core was sent to pathology and two cores were sent to microbiology.”)
4. If frozen was performed, please use add (see Connie’s macros on PowerScribe to get the “frozen” macro).
5. If the procedure was discussed with anyone prior to or after the procedure, please document this information at the end of the report (e.g. The approach for the biopsy was discussed with Dr. Kevin Raskin prior to the procedure.”; or, “The results of the biopsy were discussed with Dr. Santiago Lozano-Caulderon at 1634 on xx/yy/zzzz).
6. If conscious sedation was used, please remember to make it clear in the report ("Anesthesia" section). In the past, we were required to add the medication doses, but it has not been an issue more recently.
*Updated 7/1/2025