Case: Documentation & Process Flow
A 45-year-old male patient is admitted to the emergency department with acute abdominal pain. The attending physician orders a CT scan of the abdomen to rule out appendicitis. The patient's medical history includes hypertension and a previous appendectomy. The CT scan is performed, and images are sent to the PACS for interpretation.
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CTAI-GENERATED
The CT images show a normal appendix stump with no signs of inflammation or abscess formation. There is evidence of diverticulosis in the sigmoid colon, but no acute diverticulitis.
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What is the first step in ensuring proper documentation for this CT scan?