Implementation and evaluation of a performance improvement intervention to address physician documentation deficiencies in abdominal ultrasound.
OBJECTIVE
For ultrasound reports to meet criteria for coding as abdomen complete (USABC), 8 elements are required: liver, bile ducts, gallbladder, spleen, kidneys, pancreas, inferior vena cava (IVC), and aorta. Failure to document all 8 results in coding as ultrasound abdomen limited. The purposes of our study were to identify deficiencies in documentation, implement a performance improvement intervention to address deficiencies, and evaluate the intervention.


METHODS
In the first phase, 50 consecutive USABC reports performed as part of routine medical care were retrospectively analyzed for the presence or absence of the 8 elements required for USABC coding. Subsequently, education regarding current procedural terminology coding in abdominal ultrasound and standardized macros was provided to radiologists. In the second, postintervention phase, an additional 50 consecutive USABC reports were analyzed for the presence or absence of the 8 elements.


RESULTS
In the first phase, none (0%) of 50 reports met criteria for USABC. The most commonly omitted elements were IVC (present in 2% of reports) and aorta (present in 6%). After intervention, there was an increase to 37 reports (74%) meeting criteria for USABC. The most commonly omitted elements were IVC (present in 76%) and aorta (present in 86%). Lack of 100% compliance was secondary to failure to update a macro and inaccurately scheduled studies (focused right lower quadrant/appendicitis study scheduled as USABC).


CONCLUSIONS
We improved USABC documentation from 0% to 74%. Our compliance rate after intervention was similar to the 75.1% of previously published larger studies. Our study illustrates the efficacy of simple performance improvement interventions to improve abdominal ultrasound documentation.
Department of Radiology, Icahn School of Medicine at Mount Sinai, New York, NY.
Vivek V
VV
Patil
Bradley N
BN
Delman
Eric J
EJ
Wilck
William L
WL
Simpson
D000005:Abdomen / Q000000981:diagnostic imaging*; D002983:Clinical Competence / Q000592:standards / Q000706:statistics & numerical data*; D039702:Current Procedural Terminology; D004282:Documentation / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D009518:New York; D010818:Practice Patterns, Physicians' / Q000592:standards / Q000706:statistics & numerical data*; D011785:Quality Assurance, Health Care / Q000592:standards / Q000706:statistics & numerical data; D058996:Quality Improvement / Q000592:standards / Q000706:statistics & numerical data*; D014463:Ultrasonography / Q000592:standards* / Q000706:statistics & numerical data; D014781:Viscera / Q000000981:diagnostic imaging