Patient and Laterality Checks for Veterinary Teleradiology

Patient identification and laterality connect an imaging study to the animal and anatomical site it is meant to assess. A useful check compares the request, the clinical record, and the study itself. The patient’s name is one part of that check; the examination date, practice identifier, body region, and intended side provide the rest of the context.

The AVMA supports standardized information collection and exchange in veterinary care, including DICOM. [1] The process below is a suggested clinic-side verification method, not an AVMA-mandated checklist or a description of a particular platform’s automated safeguards. Its purpose is to make discrepancies visible before somebody relies on the study.

Use the patient identifier as well as the name

Begin with the practice’s established patient identifier and the name recorded for the animal. Check that these refer to the patient being imaged, rather than an earlier appointment or another animal belonging to the same client. A name can be familiar without being unique. Follow the practice’s identity procedure instead of creating a separate informal naming system for radiology.

When images come from another location, identifiers may differ between records. Document the connection using known information and confirm it through the appropriate record process. Do not assume that similar names establish a match. If the relationship cannot be confirmed, make the uncertainty explicit and resolve it with the responsible team before describing the material as belonging to the patient.

Identify the particular examination

One patient may have several studies on the same day or across several visits. State the examination date, modality, and body region so the request points to the intended study. Distinguish the current examination from prior material supplied for context. This is particularly important when a copied history contains references to more than one imaging event.

If the recorded date differs from the expected date, investigate the discrepancy rather than silently substituting the date of submission. Acquisition and submission are different events. Keep both understandable where they matter to the record. The goal is not an elaborate timeline for every case, but a clear connection between the clinical question and the actual examination under review.

Separate anatomical side from projection

Write the clinical site and side in plain language when the concern is side-specific. A question about a left-sided abnormality should be identifiable as such in the clinical request. The imaging team should also ensure that the study’s labels are consistent with its own acquisition records. This article does not prescribe marker placement or replace the practice’s imaging protocol.

An anatomical side and the description of a projection are different pieces of information. Avoid using a shorthand label as the sole explanation of the site being investigated. If a label is ambiguous, ask the acquisition team to clarify its intended meaning. An explicit note is preferable to expecting the interpreting radiologist to reconstruct an undocumented labeling convention from context.

Compare the request with the submitted material

Check that the requested body region matches the material selected for submission. Confirm that current images have not been confused with earlier images and that the intended examination is included. These are record checks; they do not establish whether the study is technically adequate or whether it answers the clinical question. Those require separate assessment.

Use a brief read-back between the person preparing the submission and the available source record: patient identifier, examination, region, and side where relevant. A second-person check can be part of a clinic’s chosen process, but it is not presented here as a universally required step or a proven error-reduction measure. Choose a process the team can apply consistently.

Flag uncertainty instead of guessing

If the history says one side and the study label appears to say another, preserve that discrepancy while the clinic investigates. Do not revise the clinical narrative merely to make the documents look consistent. Identify which source is being checked and who can confirm the acquisition details. Avoid declaring a labeling error until the relevant information has been established.

Any correction should follow the practice’s documentation process, with the original context and the confirmed correction distinguishable. If the case has already been sent for interpretation, communicate the issue through the available case channel. The important distinction is between a confirmed correction and an unresolved question; the record should not make one look like the other.

A short final verification

A practical final check asks: does this study belong to this patient; is this the intended examination; does the requested region match; is the side clear where relevant; are discrepancies resolved or explicitly flagged? Adapt those questions to the practice’s own protocol. Keep technical image-quality assessment and clinical decision-making separate from this administrative verification.

For a comparison request, apply the same identification checks to each earlier examination. Label the sequence clearly without overwriting original information. Once the record is consistent, the clinician can focus on the indication and the interpretation. Accurate identity and laterality documentation are the foundation for discussing the correct study, not a guarantee of a particular diagnostic result.

Frequently asked questions