ALL PROCEDURES
Currently the Header of the report auto-populates (usually with a generic "IR INJECTION" option - don't delete it). You can add a personalized header, but make sure to include both sides if doing bilateral. Each procedure should have a separate line in the impression (for correct billing).
So if you inject both shoulders (glenohumeral joints), if you want to include a personalized header, it should read:
Corticosteroid injection in the left glenohumeral joint
Corticosteroid injection in the right glenohumeral joint
And the IMPRESSION should read:
1. Fluoroscopically-guided corticosteroid and anesthetic injection of the left glenohumeral joint.
2. Fluoroscopically-guided corticosteroid and anesthetic injection of the right glenohumeral joint.
Other things that should be added to the IMPRESSION:
The needle length, for example, 5 or 7 inches for lumbar spine/hip/shoulder, 2 inches for cervical spine.
History of contrast allergy and what agent was used.
History of latex allergy.
Any other important events that occurred and how they were handled (e.g. vasovagal).
If and how the symptoms changed after the procedure.
For the "CONSENT" section:
Add 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; some of the procedure macros have an incorrect version of the “time-out” macro so please double check replace it with Ambrose’s macro).
State if the patient's parents or legal guardian were consented in the case of a minor.
State whether a translator was used.
Some of the medications and doses are wrong in the macros because the cocktails have changed through the years but the macros haven’t kept up so please double check, especially for auto populated ones (e.g. arthrograms)!
SPINE
If there is transitional anatomy, in the TECHNIQUE section of the report note how you determined the level to inject (e.g. compared with MRI, lowest mobile disc space was considered L5-S1). Also if contrast flowed to multiple locations such as additional foot joint spaces or adjacent neural foramen above or below the injection site, state it to receive credit. It may also save you from performing an additional injection.
If there has been a minor change in the procedure (e.g. the level of an epidural steroid injection), then include a statement at the beginning of the TECHNIQUE section of the report that explains the rationale, e.g. “The MRI from 3/5/2015 was reviewed. There is a paucity of epidural fat at the L4-5 level. Therefore, the L3-4 level was selected for injection.”
ARTHROGRAMS
For the MR/CT portion of all arthrograms the arthrogram portion should be included in the comparisons (i.e. COMPARISON: “Arthrogram of the same date”).
PROCEDURE MACRO LIST
The macros from the procedures are jumbled and inaccurate. Add these Macros from Connie's AutoText on PowerScribe to make your life easier
time out
MSK - arthrogram (hip/shoulder)
MSK arthrogram (hip/shoulder) - depo
MSK - biceps injection
MSK - ESI
MSK - hip injection
MSK - joint aspiration
MSK - NRB
MSK - plantar fascia inject
MSK - shoulder injection
MSK - SI injection
MSK - small joint injection
MSK - tibtalar
USINT (general ultrasound procedure dictation)
time out