Health Information Technologies and Processes

Physician Guided Ultrasound Exams

  • 1.  Physician Guided Ultrasound Exams

    Posted 04-17-2019 17:29
    I am wondering what practices concerning physician guided ultrasound examinations other facilities have adopted in regards to the retaining of these images in the legal medical record.  Currently at my facility, there is much debate about whether or not the image needs to be retained if the service is not specifically billed for and it was strictly done an in assessment-only capacity.  Some considerations are that physicians are claiming that use of the ultrasound is no different than their use of the stethoscope.

    For instance, if an Emergency Department physician performs an ultrasound to review an abscess on a patient's leg, should that image be retained even though the physician is not billing for the ultrasound service?  Or should the image be retained based on the simple fact that the physician utilized the image for the basis of patient care?

    There is a process in which these images can be retained in the legal medical record, but it does require the physician to enter in identifying information into the ultrasound machine prior to the image being completed.  The argument against this practice is that in an emergent situation, such as in the ED or the ICU, the time needed to enter in the patient's demographic data does not exist.  It would impede the urgent patient care that is needed.

    Additionally, this whole discussion gives me heartburn as I know that our facility did encounter a situation a few years ago where an intensivist performed a bed-side ultrasound on an ICU patient.  The intensivist mentioned the ultrasound within his note but did not bill for the service nor retain the image in the medical record, which is common practice here.  After the patient had passed away and the family reviewed the medical records, they demanded to see the ultrasound that the intensivist had mentioned.  The facility was not able to produce the images.

    There is much continued discussion regarding this with different areas of the work group researching standards elsewhere (i.e. American College of Surgeons stance regarding use of quick US in trauma, etc).  One thought process that was explored was the thought that the facility could implement a policy that indicates that these types of ultrasound images are not routinely kept in the normal course of business, so that would protect the facility and provider in a court of law.

    What's everyone's best practice stance on this from an HIM perspective?

    Alyssa Dennis
    Him Operations Director
    Conifer Health Solutions