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Legal, Technical, and Document Writing: Yes, it is That Important!

The documentation of the work done on all imaging equipment is required by licensing bodies. That is well known. Work orders can be used as a resource for troubleshooting and trending. This is also well recorded. But what happens when a lawyer calls down to the office and asks for all the service documentation from April 2010 to 2015 for a specific unit because of a lawsuit? How much of the work that was done on that unit was performed by you or an Independent Service Organization (ISO)? Or do you hope that whatever happened was something that happened while that unit was still under warranty? The truth is, at this point, it is too late to do anything other than copy the files, be it digital or paper copies.

The question that you should be addressing, is what can I do now to protect myself and the company I work for? Is my documentation accurate? Is my documentation complete?

Everyone who has ever turned a wrench on a CT, MRI, or X-ray system has had a point where they had so much work that they have trouble making time to document the work they have done as they do it. The new reality is that we can no longer afford to risk not documenting the work as it is done. The litigious society we live in, more than ever the documentation is part of the job.

Writing down notes on what you do while on a unit might work, but how much of it actually makes it into any electronic documentation? How often have you forgotten to write down something and could remember just enough to know that you have forgotten? So let’s consider a few ideas of how to make accurate documentation part of your workflow.

First, as part of a legal document, all of the notes or description should written as a technical document. A work order is not a narrative. What this means is that the document should be written in third person. As the individual writing and signing off on a work order, the word “I” should not appear in any writing. For example, instead of, “I inspected the fan.” it would be better and more efficient to write, “Inspected fan.” Since you are writing the document, it is assumed you are doing whatever work is listed unless you specify work by another. In that case you might write, “Bob Smith inspected the fan.”

Why does any of this matter? Simple, seven years from now you find yourself in front of a lawyer in a deposition. The lawyer is looking at a work order that you have your name on. What questions are they going to ask? If you wrote, “I waited for access to the unit.” the questions will be different than if you wrote, “Waited 1 hour for access to unit.” Similarly, if you write “Performed PM.” How does that differ if you write, “Checked 80 kv. Measured 79.5 kv” and then have the serial number of the test equipment used in testing? If you said, “drastically!” you are correct.

Some tricks to make documentation quicker. Depending on how your company documents work, some of these will work better than others. Ideally, you will have a web-based system that will have you use drop down menus for a majority of the documentation. If not, make a template from a word document with all of the most common phrases that you use. When documenting, copy and paste the template into the report and fill in the details. If you have never learned to type or keyboard (the term depends on your age) take a keyboarding class or get software that will help you learn. There are several programs that teach typing that cost less than $20. There are even a number of speech to text programs for less than $100 if your company will allow you to put it on your laptop.

Have a better idea or one I didn’t mention. Leave it below! I am always looking for a better way of doing things.

 

John has twenty years experience in imaging service including general radiation, mammography, CT, and Nuclear Medicine. He has worked for third party service companies, manufacturers sales companies, and in house imaging teams. Currently John is managing imaging service for two hospitals and six out patient centers for Kettering Health Network. John holds a B.S. in Health and Human Services Management from Wilberforce University.

 

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