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Specifications Manual for Joint Commission National Quality Measures (v2015A)
Home » Chest X-Ray

Release Notes:
Data Element
Version 2015A

Data Element Name: Chest X-Ray
Collected For: CAH-04, PN-3a,
Definition:Documentation of a chest x-ray or CT scan the day prior to hospital arrival through acute inpatient discharge.
Suggested Data Collection Question:Did the patient have a chest x-ray/CT scan the day prior to hospital arrival through acute inpatient discharge?
Format:
Length:1
Type:Alphanumeric
Occurs:1
Allowable Values:

1   There is documentation the patient had an abnormal chest x-ray/CT scan the day prior to arrival through acute inpatient discharge.

2   There is documentation the patient had a normal or chronic chest x-ray/CT scan the day prior to arrival through acute inpatient discharge.

3   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.

Notes for Abstraction:
  • 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:
    • 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.”"
    • The only documentation of an Inclusion term is prefaced with wording such as, “"no significant”" or “"no definite,"” select value "“2.”"
    • The only findings in the radiology report or physician/APN/PA documentation are chronic or normal, select value "“2."” This includes inclusion terms defined as chronic, e.g. "“The heart is difficult to assess because of a large area of consolidation and an infiltrate in the left lung field. All findings appear chronic."”
  • Any documentation in the current chart may be used. 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. If an Inclusion term is found, select value "“1"” and do not look any further. 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.
  • 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.
  • In order to select value "“1”" an Inclusion term must be documented in reference to an x-ray/CT scan interpretation. 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.
  • Both regular and portable chest x-ray results are acceptable.
  • This data element only applies to x-rays and CT scans. As long as the x-ray or CT scan shows the chest or part of the chest, it can be used.
    Example:
    If "“Infiltrate"” is listed among other findings in the radiographic report of a CT scan of the abdomen, select value "“1.”"
  • Do NOT reference Appendix H, Table 2.6.
  • If there is mention of a chest x-ray or CT scan and there is no documentation that it was performed prior to the patient arrival or during the hospitalization, assume it was performed during the hospitalization.
    Examples:
    • H&P says "“CXR performed last week at physician’s office.”" Physician note states, “"CXR shows infiltrate.”" There is no documentation of a CXR performed during the hospitalization. This will be a value "“3,"” as there is mention of a CXR performed more than 24 hours prior to arrival.
    • Physician note states, "“CXR shows infiltrate.”" No mention of a CXR performed in the hospital or prior to arrival. Assume it was during the hospitalization and select value "“1."”
Suggested Data Sources:

PHYSICIAN/APN/PA DOCUMENTATION ONLY
RECOMMENDED ORDER FOR THESE SOURCES


1. Chest x-ray report
2. Chest CT scan report
3. Other x-ray or CT scan with lung field findings
4. Physician’s notes
5. History & Physical
6. Remainder of current hospital record
Additional Notes:
Guidelines for Abstraction:
Inclusion Exclusion
ALL INCLUSIVE with the EXCEPTION of variations on terms in the list, e.g., density = dense, haziness = hazy, etc.
  • Airspace disease
  • Airspace process
  • Bronchogram
  • Bronchopneumonia
  • Consolidation
  • Consolidative process
  • Density
  • Infection
  • Infectious process
  • Infiltrate
  • Infiltration
  • Infiltrative process
  • Inflammation
  • Inflammatory process
  • Interstitial changes
  • Interstitial disease
  • Interstitial edema
  • Interstitial fibrosis
  • Interstitial pneumonia
  • Interstitial process
  • Interstitial prominence
  • Haziness
  • Lung process
  • Markings
  • Opacity
  • Opacification
  • Patchiness
  • Pneumonia
  • Pneumonic process
  • Pneumonitis
  • Positive infiltrate
  • Pulmonary process
  • Reticulonodular pattern

None

Chest X-Ray
Specifications Manual for Joint Commission National Quality Measures (v2015A)
Discharges 01-01-15 (1Q15) through 09-30-15 (3Q15)
Questions? Ask Question to Joint Commission staff Copyright © 2014 by The Joint Commission.
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