NEW DIR

In order to create a Diagnostic Imaging Report (DIR), click the  New icon at the upper left. This will open the DIR with today’s current date filled in and the defaults that had been selected in Preferences. At this point, if it is necessary to enter something different than the defaults, click on the drop down arrow in each selection box, and choose the appropriate alternative item. If the Exam Date (figure 33) needs to be changed, click the Edit Pencil to separate the date and time, and then change the date. After changing the date, click the Edit Pencil again to lock in and save the change.

                   Figure 33

Note that if the Exam Date is different than today’s current date, the DIR will NOT appear in today’s current SOAP note but will still be saved as an independent report in the DIR folder. In order for the DIR to appear in the current note, the date of the DIR must be the same as the current note being generated.

The DIR forces some items to be entered in proper sequence, or the DIR does not allow progressing to the next item.

Region Selection Box – In order to have findings, it is necessary to identify which body area was examined. Click on the Region drop down arrow to choose the specific body area(s) that was/were examined. Click on the item to select it. This activates the Views selection box.

Views Selection Box – Click on the Views drop down arrow to select the imaging views that were taken of the patient. There MUST be at least 1 view selected in order to activate the Findings.

Anomalies (figure 34) – Although the Findings Selection Box has been activated after the Views have been chosen, BEFORE entering the Findings, examine the films for Anomalies such as extra or missing vertebrae. If Anomalies are present, be sure to check them off in the Anomalies box at the upper right of the DIR window. Note that the Spine View changes accordingly, verifying that Findings can not be entered for a vertebral level that does not exist.

                   Figure 34

Findings (middle column in figure 31) are entered by clicking on the specific Finding from the Findings List. It may be necessary to use the scroll bar on the right side of the Findings box in order to locate the item needed.

Once a Finding item has been selected, there are options to include additional details, but they are not required, in the column to the right of the Findings box.

•      The first option is for Severity. Click on the Severity item so that it is highlighted. To remove the selection, click it again so the highlight disappears.

•      The second option pertains to the Location of the Finding. Simply place a check in each box that applies to the patient.

•      The third option is for Extended Detail. This additional data item does not pertain to all Findings, so there will be some Findings that do NOT offer Extended Detail selections. When there is data to select in this box, click on the Extended Detail item so that it is highlighted. To remove the selection, click it again so the highlight disappears.

For each Finding, after selecting the Finding, Severity, Location, and Extended Detail, click on the vertebral levels that the Finding applies to. There are some Findings that are NOT spine related, such as gallstones or kidney calculi. The system allows the entry of these Findings WITHOUT clicking on any vertebral levels on the Spine View. As the selections are made, they will appear in the box on the lower left of the DIR window.

Another optional section on the DIR window is Measurements (figure 35) in the column on the far right under the Anomalies.  The Measurements include George’s Line, Cervical Curve Angle, Physiological Stress Lines, Cervical Flexion/Extension Range of Motion, Sacral Base Angle, and the L3 Gravitational Plumb Line. For each Measurement that is done, place a check in the box next to its name. This activates the selection boxes under each heading.

                   Figure 35

•      George’s Line – If it is normal and unbroken, from the drop down selection box, choose Unbroken. If it is abnormal and broken, from the drop down choose Broken. As soon as Broken is selected, the Spine View will change color. On the Spine View, click on the vertebral levels at which George’s Line is broken. If it is broken at multiple adjacent levels, simply drag the mouse over those levels while holding down the left mouse button. If it is broken at multiple NON-adjacent levels, hold down the control key while using the mouse to select all the vertebrae involved.

•      Cervical Curve Angle – type in the measurement.

•      Physiological Stress Lines – Note if it is Normal or Abnormal by making the selection from the drop down box. If the Physiological Stress Lines are Abnormal, then enter the point at which they intersect in the text box.

•      Cervical Flexion/Extension Range of Motion – type in the measurement

•      Sacral Base Angle – type in the measurement

•      L3 Gravitational Plumb Line – From the left drop down box, note if it is Normal or Abnormal. Selecting Abnormal activates the 2 boxes to the right. At the far right, choose the measurement scale (inches, centimeters, or millimeters). In the middle box enter the measurement. Below the measurement, note if the line falls anterior or posterior of the anterior tip of the sacral base.