INTERPRETATION ERRORS
Unfortunately, ICAEL application reviewers occasionally identify situations in which the interpretations submitted as part of the representative case studies are not supported by the data shown on the corresponding examination. These include such issues as failure to report pathology shown, reporting pathology not actually shown, inaccurately grading severity and otherwise misinterpreting exam data. The Standards call for reports that "accurately reflect the content and results of the study" as well as localize and quantify abnormal findings.
INTERNAL INCONSISTENCIES AND TYPOGRAPHICAL ERRORS
Inadequate proofreading leads to misspelled words, incorrect grammar, and most seriously, inconsistencies within the body of the report. An ordering physician may be confused, at best, by noticing "Normal left ventricular systolic function" in the report text and "EF 20%" in the conclusion. At worst, he or she may make a clinical decision based upon the incorrect statement. Please note: Reports must be verified by the interpreting physician before being signed. The laboratory's quality assurance program should be designed and utilized in such a way to identify and eliminate errors of this nature.
REPORTS HANDWRITTEN
Handwritten reports and reports with handwritten entries or amendments are not compliant with The ICAEL Standards. Reports must be completely typed.
FINAL REPORTS NOT COMPLETED WITHIN PROPER TIMEFRAME
Related to report timeliness, The ICAEL Standards have been modified over the last few years. Part I, Section 3.2 states that the interpreting physician must complete the final interpretation within two working days. This may be in the form of dictation, handwritten copy, phone system, etc. The Standards now allow four days for the report to be finally typed, verified and signed by the interpreting physician. Signatures must be manual or electronic; stamped signatures are unacceptable.
The ICAEL reminds laboratories that many different styles of reports will conform to the Standards. All laboratories are encouraged to create a final report that epitomizes the quality work produced within their individual laboratories.
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THE ICAEL STANDARD REPORT
An Adult Transthoracic report that is compliant with The ICAEL Standards contains:
- Complete header
- Table of 2D/M-Mode measurements
- Doppler evaluation, including peak and mean gradients and valve area for stenotic valves, degree of regurgitation and evaluation of other pathology
- Complete text with the required comments on ten structures, whether normal or abnormal
- Summary of pertinent findings
- Manual or electronic signature
The report must:
- Appear in the standardized format with others from the lab
- Reflect uniform diagnostic criteria
- Accurately reflect the study data
- Contain text consistent with quantitative data
- Localize and quantify pathology
- Identify structures that were not well-visualized
- Be interpreted within two days and finally typed, verified, and signed within four days
- Avoid inconsistencies and typographical errors
- Be clear and comprehensible
Standards for other reports:
- Adult Transesophageal: Part III, Section 3.4
- Adult Stress Echo: Part IV, Section 3.5
- Pediatric Transthoracic: Part II, Section 4
- Pediatric Transesophageal: Part III, Section 3.4
- Fetal: Part IV, Section 4
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