This file contains the diagnostic codes that can be associated with an exam. The code is attached to an exam at the same time the interpreting resident and/or staff physician is entered for the exam. The diagnostic code represents a quick overall summary of what the interpreting physician wrote in his/her report concerning the exam. [NOTE: Diagnostic code is not the impression. The impression is stored in the 'IMPRESSION' field of the 'RAD/NUC MED REPORTS' file (#74).] The following is the list of codes that are loaded when the module is initialized: 1) NORMAL 2) MINOR ABNORMALITY 3) MINOR ABNORMALITY, NO ATTN, NEEDED 4) ABNORMALITY, ATTN. NEEDED 5) MAJOR ABNORMALITY, PHYSICIAN AWARE 6) UNDICTATED FILMS NOT RETURNED, 3 DAYS 7) UNSATISFACTORY/INCOMPLETE EXAM 8) POSSIBLE MALIGNANCY, FOLLOW-UP NEEDED As part of the system customization process, these entries can be deleted. However, once the system is in production, you should 'not' delete any entries. Adding new entries is always allowed. If the site decides to enter diagnostic codes for exams, then database searches can be performed using the 'DIAGNOSTIC CODE' field of the exam record in the search criteria. For example, the database can be searched for all 'normal' chest procedures. Data Storage ------------ The data for the 'DIAGNOSTIC CODES' file is stored in the ^RA(78.3, global. At the present time this file is very static after day-one initialization is complete. However, it still should be journaled. It should also be translated if the operating system supports this function. Input Templates --------------- The package does not use any input templates associated with this file. Print Templates --------------- The following is a list of print templates used by the package: Name Description; Option(s) ---- ---------------------- DIAGNOSTIC CODE PRINT Prints a list of entries in this file; RA DIAGP Sort Templates -------------- The package does not use any sort templates associated with this file.
.001number11This field contains the number of this diagnostic code. This provides a way to do quick look-ups of a diagnostic code by its number. Diagnostic code numbers are assigned by the system and are between 1 and 998. Diagnostic codes above 998 are assigned by Radiology patches. Code Number Usage ----------- ------------------------- 999-1003 Nat'l Teleradiology Prog. 1100-1106 BI-RADS 1200-1202 Abdominal Aortic Aneurysm
.01diagnostic code(+)0;1FREE TEXTBThis field contains a short diagnostic code to indicate the results of the interpreting physician's analysis of the images. Diagnostic codes can be between 3 and 60 characters in length and can be used as a basis for database searches. (ie. How many 'Normal' chest exams were performed during a specific time period?) Eight diagnostic codes are included with the original package. Other site-specific diagnostic codes may be entered by the rad/nuc med coordinator at each site.
2description0;2FREE TEXTThis field is used to give a description of the diagnostic code and may be from 1-80 characters in length.
3print on abnormal report0;3BOOLEANY:YES
This field contains a 'Yes' or 'No' value to indicate if exams with this diagnostic code should be printed on the 'Abnormal Exam Report'. The report is used to ensure that the physician is notified of abnormal results of an exam. This field must be set to 'Yes' before the diagnostic code is entered on the exam in order for that exam to appear on the 'Abnormal Exam Report'.
4generate abnormal alert?0;4BOOLEANy:YES
If this code should generate an abnormal alert, enter 'y', yes at this prompt.
6expression0;6POINTER757.01This field is associated with the .01 field used for BI-RADS codes under the MQSA coding system mandated by the FDA. Whenever the BI-RADS codes from field .01 is displayed, this field will be used to retrieve the current FDA-mandated wording for .01 field values of "BI-RADS CATEGORY 0" through "BI-RADS CATEGORY 6", which are in record numbers 1100 through 1106. The retrieved value will be displayed next to the .01 field value. This field is initially populated by patch RA*5.0*97. The Radiology application does not prompt the user for this field. Changes to data in this field will be made by future Radiology patches.

Referenced by 5 types

  1. RAD/NUC MED HL7 APPLICATION EXCEPTION (79.7) -- default dx for 'r' report, default dx for 'f' report
  2. RADIOLOGY EXTRACT (727.814) -- diagnostic code
  3. WV DIAGNOSTIC CODE TRANSLATION (790.32) -- radiology diagnostic code
  4. IMAGING SITE PARAMETERS (2006.1) -- rad primary diagnostic code
  5. DICOM GATEWAY PARAMETER (2006.563) -- importer rad dx code