Diagnostic Imaging Report

The Diagnostic Imaging Report (DIR) (figure 31) is for the doctor to record the findings from any type of diagnostic film that he/she is reading. The DIR window enables point and click selections, and then converts the selections into dictation quality English. Once the entries are saved, the system maintains them as a separate and distinct Diagnostic Imaging Report as well as placing those findings in the SOAP note, provided that the Exam Date of the report is the same as today’s current date and that the DIR is completed prior to the creation of today’s current SOAP note.

                   Figure 31