DOCUMENTATION FOR SPECIAL STUDIES
All x-rays and all special studies, radiographic or otherwise, will be documented as follows:
1.) Order written.
2.) Dated and timed entry in progress notes naming the study and giving indication for study and name of surgeon requesting study, if other than person writing note.
3.) Dated and timed entry in progress notes listing findings of study, pertinence of findings and any change in management based on findings.
All procedures requiring radiographic monitoring - as central line placement - will be documented in the same way, except that one timely note may suffice for indication and outcome.
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