Incomplete or Partial Imaging Studies
How can I tell if my imaging record is incomplete, and what should I do?
A complete record includes all image sequences, the radiologist's report, and any prior comparison studies referenced in the report. If any piece is missing, contact the HIM department in writing with specifics about what's absent, and escalate to the HIPAA Privacy Officer if needed.
You requested a copy of your MRI, and a CD arrives in the mail. But when your new doctor tries to view it, they discover that the report is missing, or key image sequences are gone. An incomplete record provides the illusion of a complete record while lacking the necessary information for a proper diagnosis or second opinion.
Common Types of Incomplete Records
A complete imaging record is a package: the images and the report, along with any relevant prior studies used for comparison. A failure in any of these areas results in an incomplete record.
1. Images Without a Report
This is one of the most common failures. You receive a CD with hundreds of images, but the radiologist's official interpretation is nowhere to be found. The images are of limited use without the report, as the report contains the detailed findings and conclusions of the expert who interpreted the study.
2. Report Without Images
Conversely, you might receive the two-page text report but none of the actual images. This is also an incomplete record. For a second opinion, another radiologist needs to see the images themselves. They cannot and will not provide a second opinion based only on another radiologist's report.
3. Missing Sequences or Views
This is a more technical failure. An MRI or CT scan is not a single picture but a series of different image sets called sequences or series. Each one is designed to highlight different types of tissue or abnormalities. A complete study may have a dozen or more of these sequences. Sometimes, due to operator error when creating the CD, only a subset is included.
4. Prior Comparison Studies Not Included
The radiology report will often state, "Comparison is made to a prior study from [Date]." This means the radiologist interpreted your new scan by comparing it to an old one to look for changes. A complete record request should include these prior studies, but they are often omitted.
Why Do Partial Records Happen?
Human Error
The person in the HIM department who created your CD may have simply forgotten to include the report PDF or failed to select all the image series for export.
System Defaults
The software used to create the patient CD may have default settings that exclude certain information unless the operator specifically chooses to include it.
Lack of Understanding
The person fulfilling the request may not understand what constitutes a "complete" record for diagnostic purposes and may think that just providing the images is sufficient.
What to Do When You Receive an Incomplete Record
If you suspect your record is incomplete, you must act quickly to get the missing information.
Identify What is Missing
Compare what you received to the checklist of a complete record:
- ✓ All image series/sequences
- ✓ The radiology report (usually a PDF)
- ✓ Any comparison studies mentioned in the report
- ✓ A working DICOM viewer
Contact the HIM Department Immediately
Call the Health Information Management department and state clearly and specifically what is missing. For example: "I received the CD of my MRI from December 15th, but it did not include the radiology report. Please send me the report."
Put the Request in Writing
Follow up your phone call with a written request (email is fine) documenting what is missing and your request to receive it. This creates a paper trail.
Escalate if Necessary
If the provider is unresponsive or claims the partial record is complete, you may need to escalate to the HIPAA Privacy Officer and, if necessary, file a complaint with the HHS Office for Civil Rights for failure to provide a complete record.
Complete Record Checklist
| Component | What to Look For | If Missing |
|---|---|---|
| Images | DICOM files (usually in DICOM folder) | Request complete image export |
| All Sequences | Multiple series for MRI/CT | Request all series/sequences |
| Report | PDF file or separate report | Specifically request radiology report |
| Viewer | Setup.exe or viewer program | Download free viewer |
| Prior Studies | Comparison imaging mentioned in report | Submit separate request for prior dates |