• Use the priority order for the Suggested Data Sources to review the medical record for documentation of acceptable terms from the Inclusions. If an Inclusion term is found, select value “1” and do not look any further. If an Inclusion term is not found after reviewing the prioritized suggested sources, continue to review the medical record for physician/APN/PA documentation of Inclusion terms.
• Do not use the “history” or “indications” portion of the chest x-ray or CT scan.
• In order to select “1” an Inclusion term must be documented in the x-ray/CT scan interpretation performed on the day of or the day prior to arrival or anytime during the hospital stay. This list is ALL INCLUSIVE.
  EXCEPTION:
  Variations on the terms in the Inclusion list are acceptable.
  Examples:
  • A variation of the Inclusion term “density” is “dense”.
  • A variation of the Inclusion term “haziness” is “hazy”.
• 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 “1.”
• If the only findings in the radiology report or physician/APN/PA documentation are chronic or normal, select “No.”

PHYSICIAN/APN/PA DOCUMENTATION ONLY
PRIORITY 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