I. INTRODUCTION

Exam Notes functionality provides an automated mechanism for the Radiologist to communicate with other critical healthcare clinicians regarding specific exams for the patient. The communication occurs in the form of a documented electronic note. The intended use for Exam Notes are exchanges between Radiologists/Residents/Fellows and the Emergency Room Physicians. The intention is to provide the ability to create a preliminary Exam Note and attach it to a specific exam. The preliminary Exam Note is then viewable on any PACS workstation for other clinical team members’ review and preliminary treatment planning. Once a final report has been authenticated, the final report becomes the official reading/diagnosis from the Radiologist. This preliminary Exam Notes is in no way intended to be the final reading, or replace interactive dialogue between the Radiologist and the Emergency Physician.

II. WORKFLOW

a. The exam is performed and images are sent to PACS.

b. The radiologist/resident or Fellow performing the preliminary reading displays the images for the specific patient exam.

c. Using the Create/View Exam Note they enter the preliminary findings.

d. Editing the Exam Note is prohibited once the note has been saved.

e. The Emergency Room Physician uses the preliminary Exam Note to determine the preliminary treatment plan.

f. After the case has been reviewed with the Attending physician, the Radiologist dictates the report.

g. Once the Dictation is complete, New Exam Notes are prohibited from being created.

h. Exam Notes previously entered continue to be viewable regardless of status.

i. If a discrepancy is identified between the preliminary and the final reading, the Radiologist contacts the Emergency Room Physician to notify them of the final findings.

j. The Final or addended reports are passed electronically from IDXRad to the GE PACS System. This is considered to be the Final Interpretation for this exam.

III. PROCEDURE

Creating Exam Notes

a. Highlight the desired exam from the Worklist and click on the Exam Note icon, or while images are displayed, move the cursor to the top of the screen in the image title bar and right click to invoke the option menu.

b. Select Create/View Exam Note.

c. Move cursor or tab down to the content box and enter the preliminary findings.

d. Enter your pager number or contact information at the end of the Exam Note.

e. Select Save to store the Exam Note or Cancel to delete the Exam Note completely.

f. Select Close to exit the Exam Note function.

Viewing Exam Notes

a. When the Exam Note icon is displayed on the Worklist, Exam Note(s) exist for the exam.

b. Identify the exam on the PACS Workstation and display the images.

Tip: Individual users have the option of automatically displaying Exam Notes when opening the exam or defaulting to the system setting. To access the auto display preference click the Utilities button, select the System Preferences tab. Check the box that reads AUTOMATICALLY DISPLAY EXAM NOTES WHEN OPENING EXAMS to see associated Exam Notes every time you open exams.

c. If you have not set your preferences, move the cursor to the top of the screen in the image title bar and right click.

d. Select Create/View Exam Note from the left side of the screen (next to report).

e. A list of all Exam Notes available for this exam displays chronologically in the top half of the dialogue box. The list shows the Creator of the Exam Note, Subject (if entered at creation) and the Exam Notes Creation Date/Time.

Tip: The top section of the dialogue box can be minimized by clicking on the up arrow. Subsequent sessions are also minimized, displaying only the actual Exam Notes.

f. Highlight the Exam Note to display the text of that specific Exam Note.

g. The scroll bar located to the right of the Exam Note can be used to move up and down through the Exam Notes.

h. Select the Close button to exit the Exam Note function.

Creating an Exam Note as a Different User

Exam Notes may be created under a different User Name than the User currently logged in.

a. Finish the text entry (refer to above) of the Exam Note.

b. Select the Create As button.

c. A new window opens containing the PACS Login screen.

d. Enter your Username and Password and select the Login tab.

e. The Created By: line updates to reflect your name as the creator of the Exam Note

f. Select Save to store the Exam Note or Cancel to delete the Exam Note.