Acceptable to report whole-body exam was done and that remainder of scan was unremarkable

Q.

When the technique of a nuclear medicine exam states that a whole-body exam was performed, must the doctor document each area of the body, or may the doctor dictate any issues found and then state “remainder of whole-body scan was unremarkable”? 

A.

 Yes, that is sufficient documentation. The doctor should document positive findings, pertinent negatives, and then a comment such as “remainder of whole-body scan unremarkable.”