05/31/2013    Kenneth Meisler, DPM

: Documenting Radiological Findings (George Stephen Gill, DPM, MBA)

Podiatry specific or not, any good EHR should
have a complete template for radiographic
findings. I am in the implementation phase with
my new EHR, Pod-Practice from 20/20, and one
thing that I found exciting was the radiograph
report. It is in an easy check-off format, you
can document both extremities with different
findings from a variety of choices, or add your
own. You can add the template to an existing note
by simply typing the word "x-ray" or save it as a
separate attachment altogether as Dr. Gill
recommended.

See an example of a radiograph report below.

X-ray Report

Patient Name: John Doe

Account No: 10000062

Provider: Foot Doctor

Radiology Ordered: 3 views right foot

Indications: Heel pain, Bunion

Views taken of Right Foot: weight bearing, AP,
Lateral, Medial-Oblique

Findings: 1st Metatarsal Phalangeal Joint:
lateral deviation of sesamoids, cyst noted in 1st
metatarsal head, increased proximal articular set
angle, elongated 1st metatarsal, increased 1st
intermetatarsal angle, Medial exostosis 1st
metatarsal head

Foreign Body: N/A

Fracture: no fracture noted

Hallux Limitus: no sign of arthritic changes noted
Hammertoes: no hammertoes noted on x-ray

Heel: Plantar calcaneal spur

Post-op: N/A

Sesamoids: Lateral deviation of sesamoids

Tailor's bunion: Lateral exostosis to 5th
metatarsal head, Increased 4th IM angle

Impression: Hallux Valgus with increased 1st
metatarsal angle, medial exostosis 1st
metatarsal, and large cyst 1st metatarsal head
Tailor's bunion with increased 4th
intermetatarsal angle Plantar calcaneal spur

Recommendations: Order MRI to evaluate large cyst
in 1st metatarsal head

5/28/2013 7:18:29 PM Electronically signed by:
Dr. Foot Doctor

Disclosure: I am a consultant for 20/20 Imaging

Kenneth Meisler, DPM, NY, NY, Kenmeisler@gmail.com

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