In the United Kingdom, regulatory requirements mandate that healthcare practices maintain comprehensive records of all radiographs taken. These records serve as an essential component of compliance and are subject to review during audits conducted by government regulatory agencies.
To meet these obligations, practices must accurately document radiographs by adding detailed entries to the patient’s chart, including relevant information about the imaging and attaching the corresponding radiograph files. This process ensures both regulatory compliance and supports ongoing quality assurance.
Topics Covered
- Classify Procedure Code as a Radiograph Code
- Configure Fee for Radiograph type as Procedure Code
- Add an Radiograph to a Patient's Chart
Classify Procedure Code as a Radiograph Code
To add any radiograph items to CareStack,
Navigate to the System Menu > select Practice Settings > Treatments > Procedures.
Click + Add New Procedure.
- Enter the necessary Code Details, such as
- Procedure Code: Enter the intended Procedure Code name.
- Description: Enter a suitable description for the code.
- Short Name: Provide the desired short name.
- Code Type: Select the code type as Radiograph.
- Treatment Type: This is chosen by default.
- Category: Choose the desired category, if needed.
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Note:
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Click Save.
A toast notification will appear on the top right stating, 'Procedure Code added successfully'.
The newly added radiograph code will appear along with the other Procedure Codes.
You can filter and view the radiograph using the Code Type.
- Click to open the Code Type drop-down menu.
- Select Radiograph and click Apply.
- This will provide you with the list of all items listed under Radiograph.
Configure Fee for Radiograph type as Procedure Code
Let's see how to add radiograph items in fee tables.
Begin by
Navigating to the System Menu > select Practice Settings > Fee Tables > Fee Schedules.
Click + Add Fee schedule.
In the Add Fee Schedule slide-out,
- Enter the necessary details,
- Name: Enter the desired name.
- Type: Choose the desired type from the drop-down.
- Description: Enter a suitable description.
- Notes: Add any necessary notes.
- Colour: Choose and set the desired colour.
- Under Category, you can choose the Radiograph Codes.
- Select the desired Procedure Code, and set the desired Fees, Future Fees and Effective Date.
- Click Save.
A toast notification will appear on the top right stating, 'Fee Schedule added successfully'.
You can find the added procedure code in the Fee Schedules grid.
Add a Radiograph to a Patient's Chart
Let's see how to add radiograph items to a patient's chart.
- Select the intended patient using the Global Search Bar.
- Click the Chart quick link.
Search for and select the newly created procedure code from the list.
A toast notification will appear on the top right stating, 'Treatment added successfully'.
Click the Radiograph Audits icon to enter additional radiograph details.
On the Radiograph Audit pop-up modal, you can enter the following details:
- Date: You can assign a date from the calendar.
- Grade: Add a grade to the Radiograph, whether the image quality is acceptable or not.
- Justification: The reason it was taken.
- Taken by: Select the person who performed the Radiograph.
- Developed by: Select the person who developed the Radiograph.
- Notes: Use this to add custom notes.
- Use the tick icon to add the details and X to discard them.
- Click the pencil icon to edit the entry or the bin icon to delete it.
- Click the + New Radiograph Audit button to add a new entry.
| Tip: The above procedures can be repeated if you want to add the Radiograph Audits in the miscellaneous code. |
- When a radiograph audit is added, edited, or deleted, a corresponding entry is automatically recorded in the Audit Trail for tracking.
Practices can use this guide to classify codes as radiograph codes and manage Radiograph Audits in CareStack.