As long as the x-ray or CT scan shows the chest or part of the chest, it can be used.Įxample: If "Infiltrate" is listed among other findings in the radiographic report of a CT scan of the abdomen, select value "∱." This data element only applies to x-rays and CT scans.Both regular and portable chest x-ray results are acceptable.If one of the following terms is documented by a physician/APN/PA you may assume a chest x-ray/CT was performed as the only way to know if one of these exists is via x-ray/scan: infiltrate, density, markings, haziness, opacity, patchiness, reticulonodular pattern. In order to select value "∱" an Inclusion term must be documented in reference to an x-ray/CT scan interpretation.Do not use the "history" or "indications" portion of the chest x-ray or CT scan, although the findings and impression portions are both acceptable.If an Inclusion term is not found continue to review the medical record for physician/APN/PA documentation of Inclusion terms until the remainder of the chart has been reviewed. If an Inclusion term is found, select value "∱" and do not look any further. The Suggested Data Sources have been placed in a recommended order for review of the medical record because these are the most likely places to find documentation of acceptable terms. Any documentation in the current chart may be used."The heart is difficult to assess because of a large area of consolidation and an infiltrate in the left lung field. The only findings in the radiology report or physician/APN/PA documentation are chronic or normal, select value "∲." This includes inclusion terms defined as chronic, e.g.The only documentation of an Inclusion term is prefaced with wording such as, "no significant" or "no definite," select value "∲.". The documentation of an Inclusion term is clearly described as a negative, for example: "no infiltrate seen," "chest x-ray negative for consolidation," select value "2.".For purposes of this data element, an abnormal chest x-ray/CT scan is defined as the documentation of an Inclusion term, with exception of the following situations:.Documentation of a chest x-ray or CT scan the day prior to hospital arrival through acute inpatient discharge.ĭid the patient have a chest x-ray/CT scan the day prior to hospital arrival through acute inpatient discharge?ġ There is documentation the patient had an abnormal chest x-ray/CT scan the day prior to arrival through acute inpatient discharge.Ģ There is documentation the patient had a normal or chronic chest x-ray/CT scan the day prior to arrival through acute inpatient discharge.ģ The patient did not have a chest x-ray/CT scan the day prior to arrival through acute inpatient discharge or Unable to Determine (UTD) from the medical record documentation if the patient had a chest x-ray/CT scan.
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