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12.6 Record keeping and reporting

Good documentation and record keeping are synonymous. Effective patient care requires documentation of diagnosis, treatment and future plans so that there is sharing of communication for all practitioners for the benefit of the patient. Many civil cases arise after an initial event and records are essential in terms of providing clarity, content, style, accuracy and comprehensiveness.

Records must:

  • be made as soon as possible after the examination
  • be accurate, comprehensive and clear
  • be written legibly
  • be free of jargon
  • be signed and dated
  • be unaltered, unless there is a mechanism for the original report to be readable
  • where changes or amendments of records are made, be signed and dated at the time the change or amendment is made.

Advice on reporting is contained in the following documents:

Standards for the Reporting and Interpretation of Imaging Investigations, RCR, (2006)29

The Scope of Practice, SCoR, (2013)30

United Kingdom Association of Sonographers (UKAS) Guidelines for Professional Working Standards: Ultrasound Practice (2008).31 UKAS merged with the SCoR on 1st January 2009.

‘Team Working in Clinical Imaging’ published jointly with the RCR in 2012.23

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