Diagnostic and Therapeutic Procedure Reports Documentation
The results of all diagnostic and therapeutic procedures become part of the patient’s health record. Diagnostic procedures include the following:
- Laboratory tests performed on blood, urine, and other body fluids
- Pathological examinations of tissue samples and tissues or organs removed during surgical procedures
- Imaging procedures of the patient’s body and specific organs (radiology, scans, ultrasounds, MRIs, PETs)
- Monitors and tracings of body functions
The results of most laboratory procedures are generated electronically by automated testing equipment. In contrast, the results of monitors, imaging, and pathology procedures require interpretation by specially trained physicians such as cardiologists, radiologists, and pathologists. These physicians document their findings in reports that then become part of the patient’s permanent record, along with copies or samples of the tracing, images, and scans.
