Most importantly, all histories need at least a symptom or sign that addresses the relevant clinical history at the maximum level of certainty. “Pain,” “swelling,” “bleeding,” “HTN” are all minimally acceptable. Knowing if the patient has a history of trauma (and knowing the mechanism) is also essential, but this alone is insufficient. The radiologist knows what you mean when you write “MVC” as the indication on a chest x-ray, but for coding purposes there needs to be a symptom or sign as well (eg. CP s/p MVC, or SOB s/p MVC). If the patient is immunocompromised and there is concern for infection, please convey the immune status (“HIV,” “kidney txp,” “lung CA on chemo”).
Histories that contain “rule out” can be of value to the radiologist, but cannot be used for reimbursement purposes. For instance, instead of “r/o apply,” “RLQ pain” will satisfy reimbursement. Similarly, “r/o PTX” means radiology will not be paid, but “chest pain” or “SOB” satisfies the insurance companies. If a proper history is first provided, and there is a specific diagnosis to which the ordering physicians wishes to attune the radiologist, feel free to specify that diagnosis in the comments field.
Here are some useful pointers for the following routinely ordered studies:
Chest X-Rays: knowing the broad indication is usually all that is necessary. For instance, “HTN,” “chest pain,” “SOB,” “fever,” or “cough” will suffice. As always, knowing the trauma history and immune status if concern for infection is important. If a procedure has been performed, please note this.
Extremity X-Rays: for extremity trauma, specify what hurts and provide relevant trauma history (including if no trauma is present). If concern for infection/osteomyelitis, specify “open wound” or “cellulitis.”
Abdominal imaging: please provide location of any symptoms (eg. RLQ, epigastric, back) and broadly any relevant clinical data (elevated WBC, elevated LFTs, hematuria). For abdominal studies relevant medical history is very useful. For abdominal plain films, a history of “r/o SBO” is insufficient; “pain” or “N/V” is satisfactory.
Neuro imaging: generally explain the symptoms/signs and laterality. “Stroke” is much less useful than “RUE weakness” or “acute onset cerebellar signs.” Minimalist, but sufficient histories include: “headache,” “neck pain,” “altered mental status.” Again, providing relevant trauma history is important. Specifying if a patient is on anticoagulants can also be helpful.