Externally Acquired Radiological Image Data and Reporting for the Clinical Routine, Conference and Boards – Legal Aspects of the Second Opinion in Germany

Abstract

Background Because of an increasing number of boards and conferences, the number of second opinion readings of externally acquired image data is growing dramatically. In this review article we intend to give medical and legal recommendations for the documentation and interpretation of externally acquired radiological data for second opinions and board presentations based on German jurisdiction.

Method Using the FAQ format as a dialog between radiologists and medical legal experts, we answer the most crucial questions regarding correct documentation and interpretation for externally acquired radiological image data based on an up-to-date literature search.

Results Based on the unity of radiological image data and the corresponding written report according to the radiation protection law, the primary report should be present when composing a second opinion. If the primary external report is not present, this should be mentioned as a limitation. All radiological second opinions should be documented in written form. This is especially important in cases of discrepant findings. Legally, the attending physician is responsible for selecting the radiological opinion. The radiologist should not rely on the written primary report without personal reevaluation. Legally, it would be considered radiological malpractice if the external image data and previous image data are not evaluated personally.

Conclusion From a legal point of view, there are explicit recommendations regarding thorough documentation of a second opinion as an independent medical service in all cases.

Key Points 

• The written external report should be present when composing a second opinion report or case presentation.

• Second opinions or external case interpretations should be documented in written form.

• It is considered malpractice to completely rely on the external written report for a second opinion.

• In discrepant radiological findings the treating physician is responsible for choosing the correct radiological interpretation.

Citation Format

• Schreyer AG, Rosenberg B, Steinhäuser RT. Externally Acquired Radiological Image Data and Reporting for the Clinical Routine, Conference and Boards – Legal Aspects of the Second Opinion in Germany. Fortschr Röntgenstr 2018; 190: 610 – 615

Key words

health policy and practice - socioeconomic issues - second opinion

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