Documentation

Documentation A. Teleradiology documentation must include, but not limited to: 1. At the originating site: a) The reason teleradiology was utilized to deliver the service including there was no local radiologists to interpret the images, b) Date(s) of service, c) Beneficiary demographic information, d) Signed consent for treatment, if applicable, e) Medical history, f) Beneficiary’s presenting complaint, g) Diagnosis, and h) Specific name/type of all diagnostic studies and results/findings of the studies. 2. At the distant site: a) Date(s) of service, b) Beneficiary demographic information, c) Medical history, d) Beneficiary’s presenting complaint, e) Diagnosis, f) Specific name/type of all diagnostic studies and results/findings of the studies, and g) Radiological images.