Mammography Workbook - CPSI Application Documentation

Mammography Workbookby Computer Programs & Systems, Inc.Computer Programs & Systems, Inc.6600 Wall StreetMobile, Alabama 36695Phone: 251.639.8100 Fax: 251.639.8214Internet Address: www.cpsinet.com

Table of ContentsITable of ContentsChapter 1 IntroductionOverview ............................................................................................................... 1............................................................................................................... 4What's NewEnhancement ......................................................................................................... 14Chapter 2 General Information............................................................................................................... 5Accessing Mammogram RecordsVia the Patient ......................................................................................................... Functions Menu5Via Hospital ......................................................................................................... Base Menu (Mammo Entry)7Via Hopital ......................................................................................................... Base Menu (Mammo Data Display)11Record Categories ............................................................................................................... 12Patient Profile ......................................................................................................... Record13Exam Data ......................................................................................................... 18Additional ......................................................................................................... Evaluation Recommendations22Additional ......................................................................................................... Evaluation Data24Findings ......................................................................................................... 26Recall ......................................................................................................... 29Mass Information ......................................................................................................... 31Notification ............................................................................................................... Letters34Recall Letters ............................................................................................................... 34Recall Process ......................................................................................................... Overview35Printing the ......................................................................................................... Recall Report36Update Recall ......................................................................................................... Record36Repeat Recall ............................................................................................................... Letters37Chapter 3 Sample LettersRepeat Recall ......................................................................................................... Process Overview37Printing the ......................................................................................................... Repeat Recall Report38Update Repeat ......................................................................................................... Recall Record38............................................................................................................... 41Overview............................................................................................................... 41Negative Notification Letters (BIRADS 1,2)............................................................................................................... 42Needs Additional Evaluation Notification Letter(BIRADS 0)............................................................................................................... 43Probably Benign Notification Letter(BIRADS 3)............................................................................................................... 443 Month Recall Letter............................................................................................................... 451 Year Recall Letter............................................................................................................... 46Repeat Recall Letter............................................................................................................... 47Recall Letter/List - Physician Cover Letter/List............................................................................................................... 48Repeat Recall Letter/List - Physician Cover Letter/ListChapter 4 Sample Reports............................................................................................................... 49Overview

IIMammography Workbook............................................................................................................... 49Mammo Data ReportsMammo Patient ......................................................................................................... Data Records50Mammo Records ......................................................................................................... Report50Mammograpy ......................................................................................................... Activity/Physician Usage Report51Positive ......................................................................................................... Mammogram Follow Up Report51Breast Ultrasound ......................................................................................................... Report51Mammography ......................................................................................................... Database Report52Mammo QA ............................................................................................................... Reports53QA Summary ......................................................................................................... All Mammograms57QA Summary ......................................................................................................... All Screening58QA Summary ......................................................................................................... All Non-Screening59QA Summary ......................................................................................................... All Screening and Non-Screening60QA Summary ......................................................................................................... Mammograms per Radiologist60QA Summary ......................................................................................................... Mammograms per Technologist62Pathology ......................................................................................................... Summary All63Patient Profile ......................................................................................................... Statistics64Mammo ............................................................................................................... Tables65Mammo Tables ......................................................................................................... Examples66Cancer Statistics ............................................................................................................... 71Chapter 5 Questionnaire and Information Tables............................................................................................................... 72Overview............................................................................................................... 72Mammography Data General Information Questionnaire............................................................................................................... 74Mammography Data Records............................................................................................................... 77Mammography Data Fields Control............................................................................................................... 78Mammography Patient Profile Statistics............................................................................................................... 79Mammography Pathology Summary............................................................................................................... 83Additional Mammo Information

Introduction 1Chapter 1Introduction1.1 OverviewThe CPSI Mammography Application provides assistance in keeping track of mammographyprocedures and statistics. Patients can receive their mammogram results via notification lettersgenerated by the system. Recall letters and/or lists can be generated for the referring physicianand/or patient to remind the patient it is time to schedule their follow-up mammogram. In addition,a report can be generated that will include all patients that have not returned after the final recallhas been sent.A patient mammogram record is automatically created for the patient when specificmammography procedures are charged. The record is composed of patient exam data basedupon State, Federal, and the American College of Radiology requirements. The mammographyrecord is composed of the following seven categories:· Patient Profile Record· Exam Data· Additional Evaluation Recommendations· Additional Evaluation Data· Findings· Recall· Mass InformationThe procedure description, patient’s age; ordering physician, technologist initials, and date ofexam are automatically entered in the Exam Data category. Information such as read date,assessment code, notification code, and recall code can also be entered into the Exam Datathrough the transcription process. The entire record will remain incomplete until the requiredinformation in each category has been completed. The status of each patient’s mammogramrecord can be monitored by display or printed report.Each mammography procedure will be a part of the patient’s permanent record. Dates of previousexams and data from the patient’s mammography record will be accessible in the system. Thisdata can be displayed and/or printed.The CPSI Mammography Application also provides a variety of statistical reports including:· Quality Assurance information such as department and radiologist productivity, technologisttotals, outcomes, trends and true/false positive/negatives. This report will print statistics for theentire department and for each individual radiologist.· Patient profile statistics including screening vs non-screening exams· Pathology report on patients recommended for biopsy or needle aspiration. This report will print© 2009 Computer Programs and Systems, Inc.

2Mammography Workbookfor the entire department and for each individual radiologist.· Statistics on number of mammograms ordered per referring physician.In addition, a mammography database is available for creating ad hoc reports.The following tables contain site specific definitions utilized in the Mammography Application:· Radiologist Initials Table· Assessment Codes· Notification Codes· Recall Codes· Findings Codes· Size Codes – Size of the Cancer· Stage Code – Stage of the cancer (usually I- IV with some variations between)· Age: Path/Profile Table· Menarche Age: Profile Table· First Birth Age: Profile Table· True/False Pos/Neg Table· Technologist Initials Table· Biopsy Type Table· Mass Shape· Mass Region· Mass Margins· Mass Density Modifier· Mass Calcification· Breast Surgery Table· Breast Composition Table· Type MammogramAssessment codes are the Radiologist’s impression of the Mammogram. According to the© 2009 Computer Programs and Systems, Inc.

Introduction 3Mammography Quality Standards Act (MQSA) guidelines, each site must have at least ONEASSESSMENT CODE FOR EACH OF THE FOLLOWING CATEGORIES:· B – Benign· N – Negative· M – Highly suspicious of malignancy – Appropriate action should be taken· S – Suspicious Abnormality – Biopsy should be considered• If an “S” or “M” code is entered, the system will automatically make an entry Y (yes) in theBiopsy Required field (if used by site), when auto entry “Biopsy Rec” for access S & M is alsodefined as Y (yes).· P – Probable benign finding – Short Interval follow-up suggested, Classification needed• “N”egative or “U”nresolved· X – Unresolved, Patient never came back· 0 (zero): Need additional images, record is unresolved· If the facility is using American College of Radiology standards for assessment codes(BI-RADS), each facility must have at least one assessment code for each of the followingcategories:• 0 – (zero): Needs additional image evaluation• 1 – Negative• 2 – Benign Finding• 3 – Probably Benign Finding-Short interval follow-up suggested• 4 – Suspicious Abnormality-Biopsy should be considered.• 5 – Highly Suggestive of Malignancy-Appropriate action should be taken.• 6 – Known Biopsy-Proven Malignancy-Appropriate action should be taken.NOTE: The BIRAD 6 code is an optional code to be used if a site deems necessary. This categoryis reserved for lesions identified on the imaging study with biopsy proof or malignancy prior todefinitive therapy.This category is appropriate for second opinions on findings previously biopsiedand shown to be malignant.Findings codes are only entered on those patients where a breast specimen has been obtained(either Fine Needle Aspiration (FNA) or Biopsy). These findings will come from the Pathologyreport. Each site MUST HAVE AT LEAST ONE FINDING CODES FOR EACH OF THEFOLLOWING CATEGORIES:· C – Cancer· L – High Risk Lesion· Y – Cyst (Benign)· B – Benign (Any other benign finding other than a cyst.)· N – No findings (Patient did not have a recommended follow-up.)© 2009 Computer Programs and Systems, Inc.

4Mammography Workbook1.2 What's NewThis section introduces the new features and improvements for Mammography Workbook forrelease Version 16. A brief summary of each enhancement is given referencing it's particularlocation if applicable.Each enhancement includes the Work Request (WR) Number, the description and theimplemented release Version. If further information is needed, please contact CPSI.Enhancement 1DESCRIPTION: Some Maps have been changed to newer mapsDOCUMENTATION: See entire User Guide© 2009 Computer Programs and Systems, Inc.

General Information 5Chapter 2General Information2.1 Accessing Mammogram RecordsThe mammogram record can be accessed from the Patient Functions Menu or the Hospital BaseMenu via the following pathways:· Patient Functions Menu - Mammo Maintenance· Hospital Base Menu - Department Specific, Mammo System, Entry· Hospital Base Menu - Department Specific, Mammo System, Data DisplayVia the Patient Functions Menu1. Select the patient by entering the patient account number on the Hospital Base Menu or thePatient Functions Menu.2. From the Patient Functions Menu of the selected patient, select Mammo Maintenance.Select Hospital Base Menu > select patientFigure 2.1 Patient Functions Screen Mammo Maintenance3. A list of the patient’s previous and current mammogram records will be displayed. The examdate and complete status (YES or NO) of each record category will be listed for eachmammogram record. The record category will be incomplete until all required fields other thanthe COMMENTS field are completed. The following options may be selected:· To document mammography information, select the desired mammogram record and theselect Edit.© 2009 Computer Programs and Systems, Inc.

6Mammography Workbook· Create NEW Record to create a new mammogram record for the selected patient.· Print to print a selected mammogram record.Select Patient Functions Menu > Mammo MaintenanceFigure 2.2 Mammo Maintenance Screen4. A screen indicating the status (YES for complete or NO for incomplete) for each recordcategory of the mammogram record will be displayed. The date and initials of the technologistthat last modified the record will be displayed. The record category will be incomplete until allrequired fields other than the COMMENTS field are completed. The following options may beselected:· Select the desired record category to view, add, or change information in the selectedcategory or Entire Record.· Delete to delete the mammogram record. (Mammogram records would need to be deleted if aprocedure was canceled. Canceling a mammogram procedure does not affect a createdmammogram record.)© 2009 Computer Programs and Systems, Inc.

General Information 7Select Patient Functions Menu > Mammo Maintenance > Seq #Figure 2.3 Mammo RecordVia Hospital Base Menu (Mammo Entry)1. From the Hospital Base Menu, select Department Specific.Figure 2.4 Hospital Base Menu© 2009 Computer Programs and Systems, Inc.

8Mammography Workbook2. From the Ancillary Department Functions Menu, select Mammo System.Select Hospital Base Menu > Department Specific > Mammo SystemFigure 2.5 Ancillary Department Functions (Mammo System)3. From the Mammography System Menu, select Mammo Entry.© 2009 Computer Programs and Systems, Inc.

General Information 9Select Hospital Base Menu > Department Specific > Mammo System > Mammo EntryFigure 2.6 Mammo Entry4. Type the patient’s account number. A list of the patient’s previous and current mammogramrecords will be displayed. The exam date and complete status of each category will be listed foreach mammogram record. The following options may be selected:· To document mammography information, select the desired mammogram record and theselect Edit.· Create NEW Record to create a new mammogram record for the selected patient.· Print to print a selected mammogram record.© 2009 Computer Programs and Systems, Inc.

10Mammography WorkbookSelect Hospital Base Menu > Department Specific > Mammo System > Mammo EntryFigure 2.7 Mammo Records5. To document mammography information, select the desired mammogram record and theselect Edit.6. A screen indicating the status (YES for complete or NO for incomplete) for each recordcategory of the mammogram record will be displayed. The date and initials of the technologistthat last modified the record will be displayed. The record category will be incomplete until allrequired fields other than the COMMENTS field are completed. The following options may beselected:· Select the desired record category to view, add, or change information in the selectedcategory or Entire Record.· Delete to delete the mammogram record. (Mammogram records would need to be deleted if aprocedure was canceled. Canceling a mammogram procedure does not affect a createdmammogram record.)© 2009 Computer Programs and Systems, Inc.

General Information 11Select Hospital Base Menu > Department Specific > Mammo System > Sel Seq > EditFigure 2.8 Mammo RecordVia Hopital Base Menu (Mammo Data Display)1. From the Hospital Base Menu, select Department Specific.2. From the Ancillary Department Functions Menu, select Mammo System.3. From the Mammo System Menu, select Data Display.© 2009 Computer Programs and Systems, Inc.

12Mammography WorkbookSelect Hospital Base Menu > Department Specific > Mammo System > Data DisplayFigure 2.9 Mammo Data Records Via Mammo Data Display2.2 Record CategoriesThe Mammogram Record meets Federal Government and American College of Radiologyguidelines. The record is composed of seven individual categories. Each hospital will determinewhich questions within each category will require a response. The entire mammogram record willremain incomplete until all required questions in each category have been addressed. The“complete” status (YES or NO) of the entire record as well as each individual category is indicatedon the Mammography System screen. The mammogram record is composed of the followingcategories:· Patient Profile Record· Exam Data· Additional Evaluation Recommendations· Additional Evaluation Data· Findings· Recall· Mass Information© 2009 Computer Programs and Systems, Inc.

General Information 13Patient Profile RecordThe Mammography System Patient Profile Data consists of 11 questions and a comment field todocument additional information. Each facility has the option to designate any or all of the 12fields as required patient information for the mammogram record. The Patient Profile Recordcategory will remain incomplete until all required fields have been addressed. The required fieldsare defined in the Mammography Data Fields Control table.1. From the Mammography System screen for the selected patient, select Patient Profile Record.CAUTION: The entire mammogram record can be deleted by selecting Delete. A mammogramrecord should only be deleted when a second record is created in error. Please refer to sitespecific policies.Select Patient Functions Menu > Mammo MaintenanceFigure 2.10 Mammo Record (Patient Profile Record)2. The Patient Profile Data for the selected patient will be displayed and include the followingdemographic information:· Date of Birth· Social Security Number· Medical Record Number© 2009 Computer Programs and Systems, Inc.

14Mammography Workbook· X-Ray Film Number· Exam Date· Last Modified Date and InitialsSelect Patient Functions Menu > Mammo Maintenance > Patient Profile RecordFigure 2.11 Patient Profile Page3. The following information will be displayed when the patient has a previous mammogram recordand may be copied into the current mammogram record.· Menarche Age· Age at First Birth· Still Menstruating· Hysterectomy· Patient on Hormones· Past Menopause· Family History© 2009 Computer Programs and Systems, Inc.

General Information 15· Prior Breast Surgery4. Select one of the following options:· Copy to copy previous profile data.· Exam Data to access the next record category.5. Complete the Patient Profile Record with the appropriate information:· Menarche Age: Enter the age the patient began menstruation. (No entry is needed for malepatients.)· Age at First Birth: Enter the age of the patient when her first child was born or “N” fornulliparous. (No entry is needed for male patients.)NOTE: Enter “U” for any of the following fields that do not apply.· Still Menstruating: Enter Y (yes), N (no), or U (unknown).· Hysterectomy: Enter Y (yes), N (no), or U (unknown).· Patient on Hormones: Enter Y (yes), N (no), or U (unknown).· Past Menopause: Enter Y (yes), N (no), or U (unknown).· Family History: Enter Y (yes), N (no), or U (unknown).· Clinical Symptoms: Enter Y (yes), N (no), or U (unknown).Clinical Symptoms is a required question. The Y (yes) or N (no) response entered in thisfield (N = screening, Y = non-screening) determines whether the mammogram isSCREENING or NON-SCREENING.CAUTION: It is recommended that U (unknown) is used with caution. Records that have a “U” inthis field will not be included in the QA Summary Report as screening or non-screening statistics.· An entry of Y (yes) or N (no) in this field is required for the system to calculateTrue/False/Pos/Neg.· The calculation of True/False/Pos/Neg is required for the mammogram record to beconsidered resolved.· The calculation of True/False/Pos/Neg is what determines the mammogram record to beresolved.· The QA Summary Report provides statistics on resolved records only.• Palpable Finding - Enter Y (yes), N (no), or U (unknown).· An entry of Y (yes) or N (no) in this field is required for the system to calculateTrue/False/Pos/Neg.© 2009 Computer Programs and Systems, Inc.

16Mammography Workbook· The calculation of True/False/Pos/Neg is required for the mammogram record to beconsidered resolved.· The calculation of True/False/Pos/Neg is what determines the mammogram record to beresolved.· The QA Summary Report provides statistics for screening and non-screening mammogramson resolved records only.NOTE: For an explanation of the True/False Pos/Neg calculation, see Mammography ControlTables section of this manual.· Breast Composition: Enter the code corresponding to the breast composition descriptiondefined in Breast Composition Table , enter a question mark (?) or select the magnifyingglass to display the table and make a selection. This field will update the corresponding fieldon the Exam Data Page.· Prior Breast Surgery: Enter Y (yes), N (no), or U (unknown). If answered Y (yes), the optionSurgery History will appear at the top of the screen.· Comments: Type any additional free-text information to be documented in the record.Select Patient Functions Menu > Mammo MaintenanceFigure 2.12 Surgery History Page· Exam Data to access the next record category.© 2009 Computer Programs and Systems, Inc.

General Information 176. To document prior surgical history, select Surgery History. The Mammography System PriorBreast Surgery screen will be displayed. A total of 10 surgical procedures can be documented.Select Patient Functions Menu > Mammo Maintenance > Patient Profile Record > 2 > SurgeryHistoryFigure 2.13 Surgery History· Click on Date Tab and enter the date of the surgical procedure.· Enter the procedural description code or a question mark (?) to display a Breast Surgery Codelook-up table from which to make a selection.· Enter the location of the surgical procedure (R-Right Breast or L-Left Breast).· Enter the outcome of the surgical procedure (P-Positive, N-Negative or U-Unknown).© 2009 Computer Programs and Systems, Inc.

18Mammography WorkbookExam DataThe Mammography System Exam Data category consists of 12 fields including a comment field todocument additional information. Each facility has the option to designate any or all of the 12fields as required patient information for the mammogram record. The Exam Data category willremain incomplete until all required fields have been addressed. The required fields are defined inthe Mammography Data Fields Control table.1. From the Mammography System screen for the selected patient, select Exam Data.Select Patient Functions Menu > Mammo MaintenanceFigure 2.14 Mammo Record2. The Exam Data for the selected patient will be displayed and include the following demographicinformation:· Date of Birth· Social Security Number· Medical Record Number· X-Ray Film Number· Exam Date· Last Modified Date and Initials© 2009 Computer Programs and Systems, Inc.

General Information 19Select Patient Functions Menu > Mammo Maintenance > Exam DataFigure 2.15 Exam Data Page3. The following information will be entered automatically when the procedure is charged; it can beupdated as needed:· The Ordering Physician’s name and specific information regarding notification and recallinstructions.· The Procedure description and item master number.· The Exam Date.4. The following options can be selected at the command line:· Reprint Recall to reprint the patient’s recall letter.· Add Evaluation to display to the next record category (Additional EvaluationRecommendations).· Patient Profile to display the previous record category (Patient Profile Record).5. Select the following:· Type Mammogram: Enter the type Mammogram code for the procedure, enter a questionmark (?) or select the magnifying glass to display a Type Mammo Code look-up table. Each© 2009 Computer Programs and Systems, Inc.

20Mammography Workbookmammography procedure can be defined as one of the following 5 possible classifications:• Class A = First Mammogram• Class B = Regular Interval Return• Class C = Scheduled Short-Term Interval Return• Class D = Early Return• Class E = Late Return· Done by (TECH): Enter the initials of the person performing the procedure, enter a questionmark (?) or select the magnifying glass to display a Tech look-up table.NOTE: The following information can be automatically entered into the Exam Data category bythe transcriptionist immediately following transcription:· Read by (Radiologist)· Read Date· Assessment Category· Notification Code· Recall Code· Read by (Radiologist): Enter the initials of the radiologist who read the mammogram, enter aquestion mark (?) or select the magnifying glass to display a Radiologist Initials look-uptable.· Read Date: Enter the date the mammogram was read.· Assessment Code: Enter the assessment code , enter a question mark (?) or select themagnifying glass to display an Assessment Code look-up table. Assessment codes are theRadiologist’s impression of the mammogram. According to the Mammography QualityStandards Act (MQSA) guidelines, each facility must have at least one assessment code foreach of the following categories:• B—Benign Finding• N—Negative• M—Highly suspicious of malignancy: appropriate action should be taken.• S—Suspicious abnormality. Biopsy should be considered.• P—Probable benign finding. Short interval follow-up suggested.• X—Unresolved. Additional patient data not obtained.• 0 (zero)—Need additional imaging evaluation.· If the facility is using American College of Radiology standards for assessment codes(BI-RADS), each facility must have at least one assessment code for each of the followingcategories:• 0 – (zero): Needs additional image evaluation• 1 – Negative• 2 – Benign Finding• 3 – Probably Benign Finding-Short interval follow-up suggested• 4 – Suspicious Abnormality-Biopsy should be considered.• 5 – Highly Suggestive of Malignancy-Appropriate action should be taken.• 6 – Known Biopsy-Proven Malignancy-Appropriate action should be taken.© 2009 Computer Programs and Systems, Inc.

General Information 21NOTE: The BIRAD 6 code is an optional code to be used if a site deems necessary. This categoryis reserved for lesions identified on the imaging study with biopsy proof or malignancy prior todefinitive therapy. This category is appropriate for second opinions on findings previously biopsiedand shown to be malignant.· If an assessment code of B-Benign or N-Negative is entered, the remaining mammogramcategories as well as the entire mammogram record will be considered complete automaticallyupon completion of the Patient Profile Data and the Exam Data categories.· If an assessment code of M-Highly suspicious of malignancy or S-Suspiciousabnormality is entered, a Y (yes) will automatically be entered for Biopsy Recommended inthe Additional Evaluation Recommendations category if indicated in the MammographyGeneral Control table. (This is optional.)· If an assessment code of X-Unresolved is entered, the remaining mammogram categories aswell as the entire mammogram record will be considered complete upon completion of thePatient Profile Data and the Exam Data, but considered unresolved and will not be included inthe statistics on the QA Summary Report. It is recommended that this only be used when thepatient never returned for additional procedures.· If an assessment code of 0 (zero)-Need additional imaging evaluation is entered, themammogram record is considered a positive mammogram when used in a screening setting(Clinical Symptoms = N) and will have a true/false/positive/negative calculation determinedfrom the response entered in field 6-Cancer Found Later of the Findings category. An entryis required in field 6-Cancer Found Later of the Findings category for thetrue/false/positive/negative to be calculated and the mammogram record to be consideredcomplete. The mammogram record, however, will be considered unresolved until theadditional recommendations and corresponding data fields have been addressed. When thepatient returns for the additional evaluation, a new mammogram record will be created.· Notification Code: Enter the notification code , enter a question mark (?) or select themagnifying glass to display a Notification Code look-up table. Notification codes indicate theappropriate type of mammogram result letter that is sent to the patient.· Recall Code: Enter the recall code , enter a question mark (?) or select the magnifying glassto display a Recall Code look-up table. Recall codes indicate the time interval suggested forthe next mammogram.· Breast Composition: Enter the code corresponding to the breast composition descriptiondefined in Breast Composition Table , enter a question mark (?) or select the magnifyingglass to display the table and make a selection. This field will update the corresponding fieldon the profile page.NOTE: Recall codes should not be entered until all additional evaluation data and findings havebeen completed.· Comment: To document any additional free-text information.© 2009 Computer Programs and Systems, Inc.

22Mammography WorkbookAdditional Evaluation RecommendationsNOTE: It is not necessary to enter information in this record category if the assessment code isB-Benign or N-Negative. This record category will be completed automatically when the patient’s assessment code is B-Benign or N-Negative and the Patient Profile Record and Exam Datacategories are complete.The Mammography System Additional Evaluation Recommendations category consists of 10fields including a comment field to document additional information. Each facility has the option todesignate any or all of these fields as required patient information for the mammogram record.Therequired fields are defined in the Mammography Data Fields Control table.The Additional Evaluation Recommendations will remain incomplete until:· All fields have been addressed with a Y (yes) or N (no) response, (N must be entered foroptions that are not recommended) and/or· Both of the previous record categories have also been completed.· If Y (yes) has been entered in any of the additional evaluation recommendation fields, the entiremammogram record will remain incomplete until the corresponding Additional Evaluation Datafield has been completed with one of the following options:• Y (yes) and the date of the procedure.• N (no) if the patient did not return for the additional procedures.1. From the Mammography System screen for the selected patient, select Additional EvaluationRecommendations.© 2009 Computer Programs and Systems, Inc.

General Information 23Select Patient Functions Menu > Mammo MaintenanceFigure 2.16 Mammo Record2. The Additional Evaluation for the selected patient will be displayed and include the followingdemographic information:· Date of Birth· Social Security Number· Medical Record Number· X-Ray Film Number· Exam Date· Last Modified Date and Initials© 2009 Computer Programs and Systems, Inc.

24Mammography WorkbookSelect Patient Functions Menu > Mammo Maintenance > Additional Evaluation RecommendationsFigure 2.17 Additional Evaluation Page3. The following options may be selected:· Findings to display the next record category (Findings).· Exam Data to display the previous record category (Exam Data).4. Select the individual fields and enter the appropriate response in each field.· N (no) must be entered for options that are not recommended.· If Y (yes) is entered in the recommendation fields, the corresponding Data field(s) must alsobe completed.NOTE: When an assessment code of M or S has been entered in the Exam Data category, fieldBiopsy Recommended will automatically have Y (yes) entered if so defined in theMammography Control Table.Additional Evaluation DataThe Mammography System Additional Evaluation Data category consists of 10 fields including acomment field to document additional information. Each facility has the option to designate any orall of these fields as required patient information for the mammogram record. The required fieldsare defined in the Mammography Data Fields Control table.The Additional Evaluation Data will remain incomplete until:© 2009 Computer Programs and Systems, Inc.

General Information 25· All fields in the Additional Evaluation Recommendation category have been addressed with a Y(yes) or N (no) response, (N must be entered for options that are not recommended) and/or· The corresponding Data fields for which additional evaluation recommendations are indicatedare updated with dates following the additional procedures, and/or· Both of the previous record categories have also been completed.1. From the Mammography System screen for the selected patient, select Additional EvaluationData.2. The Additional Evaluation for the selected patient will be displayed and include the followingdemographic information:· Date of Birth· Social Security Number· Medical Record Number· X-Ray Film Number· Exam Date· Last Modified Date and Initials© 2009 Computer Programs and Systems, Inc.

26Mammography WorkbookSelect Patient Functions Menu > Mammo Maintenance > Additional Evaluation DataFigure 2.18 Additional Evaluation Data3. The following options may be selected:· Findings to display the next record category (Findings).· Exam Data to display the previous record category (Exam Data).4. Select the individual fields and enter the appropriate response in each field.· N (no) must be entered for options that are not recommended.· If Y (yes) is entered in the recommendation fields, the corresponding Data field(s) must alsobe completed.NOTE: If the additional evaluation data was not performed, an N must be entered in theappropriate fields and a comment entered with an explanation as to why it was not performed.NOTE: This record category will be completed automatically when the patient’s assessment codeis B-Benign or N-Negative and the Patient Profile Record and Exam Data categories arecomplete.FindingsNOTE: This record category will be completed automatically when the patient’s assessment codeis B-Benign or N-Negative and the Patient Profile Record and Exam Data categories arecomplete.© 2009 Computer Programs and Systems, Inc.

General Information 27The Mammography System Findings category is utilized after the breast tissue has beenexamined by a pathologist. This category consists of 7 fields and a comment field to documentadditional information. Each facility has the option to designate any or all of these fields asrequired information for the mammogram record. The required fields are defined in theMammography Data Fields Control table. The Findings category will remain incomplete until allrequired fields have been addressed.1. From the Mammography System screen for the selected patient, select Findings.Select Patient Functions Menu > Mammo MaintenanceFigure 2.19 Mammo Record2. The Findings category for the selected patient will be displayed and include the followingdemographic information:· Date of Birth· Social Security Number· Medical Record Number· X-Ray Film Number· Exam Date· Last Modified Date and Initials© 2009 Computer Programs and Systems, Inc.

28Mammography WorkbookSelect Patient Functions Menu > Mammo Maintenance > FindingsFigure 2.20 Findings Page3. The following options may be selected:· Recall to display the next record category (Recall).· Add Evaluation to display the previous record category (Additional Evaluation Data).4. Options for the following fields are defined in the Mammo Control Tables (DepartmentSpecific-Mammo System-Table Maintenance). Select the following to enter:· Findings: The defined Findings code or enter a question mark (?) to display a Findings Codelook-up table. A findings code of C-Cancer will be included in the cancer statistics on the QASummary report and the on-line Cancer Statistics option.· Palpable Cancer: (Retrospective Finding, only after Mammo): Enter Y (yes) or N (no). Anentry is made in this field to document that cancer was found after the mammogram. Thisentry is used in the True/False/Pos/Neg calculations.· Example: Palpable Finding was negative in the Patient Profile Data, but upon further testing,cancer was diagnosed.· Size: The defined Size code for the lesion/tumor can be entered, a question mark (?) orselect the magnifying glass to display a Size Code look-up table.· Stage: The defined Stage code can be entered, a question mark (?) or select the magnifying© 2009 Computer Programs and Systems, Inc.

General Information 29glass to display a Stage Code look-up table. These codes can be site specific and based onthe pathologist findings or can include default stage codes.· True/False Pos/Neg:• If the system auto-calculates True/False Pos/Neg, ( If True/False Positive/Negativecalculated by program in Mammo General Control Table is check marked (Ö) ) this field willhave an entry, provided that the mammogram fields used in the calculation have an entry.NOTE: When a field used in this calculation has been changed, the system will re-calculateTrue/False Pos/Neg and update this field.• This field can be changed by the technologist, IF True/False Positive/Negative is enabled,Allow user to change in the Mammo General Control table is check marked (Ö)• If the system does not auto calculate True/False Pos/Neg, the technologist will enter thedefined code, a question mark (?) or select the magnifying glass to display a True/FalsePos/Neg code look-up table.• An entry of Y (yes) or N (no) in Clinical Symptoms and Palpable Finding (Patient ProfileData) is required for the system to calculate True/False/Pos/Neg.• The calculation of True/False/Pos/Neg is required for the mammogram record to beconsidered resolved.• The calculation of True/False/Pos/Neg is what determines the mammogram record to beresolved.• The QA Summary Report provides statistics for screening and non-screening mammogramson resolved records only.· Cancer Found Later: Y (yes) or N (no). Cancer Date: If answered Y (yes), enter the date.An entry is made in this field to document that cancer was found at a later date(retrospective). Example: If information has been received that the patient has beendiagnosed with cancer, this field should be updated in each of the patient’s prior mammogramrecords with the information. This field defaults to blank. An entry of Y (yes) or N (no) isrequired for the record to be considered complete.· Biopsy Type: The defined Biopsy Type code is entered, a question mark (?) or select themagnifying glass to display a Biopsy Type Code look-up table.· Comments: Information to be included in the record.RecallThis option should only be accessed to remove a patient from the recall list. The MammographySystem Recall category consists of 7 possible fields and should not be confused with the recallfield in the Exam Data category that must be completed before the entire record can becompleted. Each facility will determine the number of recall letters that will be sent to patients.This information is defined in the Mammography Data Fields Control table. This record categoryis not required to be complete in order for the entire mammogram record to be completed. Thesefields will automatically be completed when recall reports are generated and then updatedwith the appropriate information.© 2009 Computer Programs and Systems, Inc.

30Mammography Workbook1. From the Mammography System screen for the selected patient, select Recall.Select Patient Functions Menu > Mammo MaintenanceFigure 2.21 Mammo Record2. The Recall category for the selected patient will be displayed and include the followingdemographic information:· Date of Birth· Social Security Number· Medical Record Number· X-Ray Film Number· Exam Date· Last Modified Date and Initials© 2009 Computer Programs and Systems, Inc.

General Information 31Select Patient Functions Menu > Mammo Maintenance > RecallFigure 2.22 Recall Page3. The following options may be selected:· Mass Info to display the next record category (Mass Information).· Findings to display the previous record category (Findings).4. Place a Y in the Stop Recall field to exclude the patient from the recall process when thepatient has moved away from the area or has expired.Mass InformationThe Mammography System Mass Information category is optional. Each facility will determinewhether this category will be included in the mammogram record. This is defined in theMammography General Control table. This category consists of 9 fields to document data for 5separate masses. Field Location is the only field required to complete the category.1. From the Mammography System screen for the selected patient, select Mass Information.NOTE: The Entire mammogram record can be deleted by selecting Delete.© 2009 Computer Programs and Systems, Inc.

32Mammography WorkbookSelect Patient Functions Menu > Mammo MaintenanceFigure 2.23 Mammo Record2. The Mass Information category for the selected patient will be displayed and include thefollowing demographic information:· Date of Birth· Social Security Number· Medical Record Number· X-Ray Film Number· Exam Date· Last Modified Date and InitialsThe current number of Mass Records will also be displayed.© 2009 Computer Programs and Systems, Inc.

General Information 33Select Patient Functions Menu > Mammo Maintenance > Mass InformationFigure 2.24 Mass Information Page3. The following options may be selected:· Recall to display the previous record category (Recall).4. Select the following to record:· Mass Number: Up to 5 separate masses may be recorded. This field automatically defaults to1 when this record category is accessed. To remove all information for the indicated massnumber, select Delete. The system will prompt for confirmation.· Location: Enter L, R, or B to indicate within which breast the mass is located.This field isrequired to complete the category.· Shape: Enter the defined mass shape code ,enter a question mark (?) or select themagnifying glass icon to display a Mass Shape code look-up table. These codes are sitespecific; for example: Irregular, Round, etc.· Region: Enter the defined region code ,enter a question mark (?) or select the magnifyingglass icon to display a Mass Region code look-up table.These codes are site specific; forexample: Right upper quadrant, Right lower quadrant, etc.· Margins: Enter the defined margin code ,enter a question mark (?) or select the magnifyingglass icon to display a Margins code look-up table. These codes are site specific; for example:Poorly defined, Clear, etc.© 2009 Computer Programs and Systems, Inc.

34Mammography Workbook· Density Modifier: Enter the defined density modifier code (for the mass) ,enter a questionmark (?) or select the magnifying glass icon to display a Density Modifier code look-up table.These codes are site specific; for example: Solid, Fibrocystic, etc.· Calcification: Enter the defined calcifications code ,enter a question mark (?) or select themagnifying glass icon to display a Calcifications code look-up table. These codes are sitespecific; for example: Speckled, Clusters, etc.)· Clockface Location: Enter the clockface location of the mass. These codes are site specific;for example: 09, 12, etc.· Size: Enter the mass size.2.3 Notification LettersNotification letters inform the patient about the outcome of their mammogram. The MammographyQuality Standards Act (MQSA) requires that “a summary of the written (mammography) reportshall be sent to the patient [by the interpreting physician] in terms easily understood by a layperson”. This applies to every patient who receives a mammogram, not only self-referred patients.The MQSA also requires that the official mammography report sent to the referring medicalcolleagues and self-referred patients include the final mammographic assessment (BI-RADSterminology) somewhere in the report. The actual word description must appear. Sample lettersfor each BI-RAD category are included in the next chapter.The appropriate notification letter will be printed for each patient based on the notification codeentered in the Exam Data category of the Mammogram Record. The contents and format of theindividual letters are hospital defined. A copy of the patient’s notification letter can also be sent tothe referring physician with an accompanying cover letter. This is controlled in the PhysicianMaintenance Table of the Business Office Tables and is based on individual physicianpreferences.Notification letters can be printed by one of the following mechanisms:· Following transcription for an individual patient• From the Radiology Result Review screen• From Medical Records Result Review screen· From the Hospital Base Menu option Print Reports, Notification Letters for an individualpatient or en-mass.2.4 Recall LettersRecall letters remind patients that it is time to schedule their next mammogram. The appropriateletter for the recall interval (3 month, 6 month, 1 year return, etc.) will be printed based on therecall code entered in the Exam Data category of the Mammogram Record. Letters can be foldedin a “Z-style” to be placed in a windowed envelope. Mailing labels can also be generated for therecall letters if windowed envelopes are not used. The body and format of the letter are hospital© 2009 Computer Programs and Systems, Inc.

General Information 35defined, but will include:· Patient’s Name· Address· Previous exam and exam date· Physician nameRecall letters are generated at the beginning of each month for the current month to allow patientsadequate time to schedule their mammogram. If the patient is due for a mammogram and hasalready had a visit within the recall period specified, then the patient will not be included in therecall process.Several options exist for Recall letters.· A letter sent to the patient.· A letter sent to the physician.· A letter sent to both the patient and physician.· A copy of the patient’s recall letter and a list of all patients due to return can also be sent to thereferring physician with an accompanying cover letter. The list will include:• Patient’s Name• Index Number• Account Number• Age• Sex• Ordering Physician• Exam date• Recall code and description.This is controlled in the Physician Maintenance Table of the Business Office Tables and is basedon individual physician preferences.Recall Process OverviewThe Recall Process should always proceed in the following order:1. Print the Recall Report – Review the report for patients without recall codes. Add theappropriate recall codes if necessary and re-generate the report if changes have been made.This is important because the letters print based on the information generated on the last reportfrom that workstation.2. Print the Letters/Lists – Prints the patient letters and lists of patients due to return for thephysicians (must be generated from the same workstation that generated the Recall Report).3. Print the patient address Labels – Prints patient address labels to be placed on recall letterenvelopes.4. Update – This updates the mammogram records with the technologist initials, date and© 2009 Computer Programs and Systems, Inc.

36Mammography Workbookcomments. This is applied to the recall page of the mammogram record. It is very importantthat the letters/lists are checked for accuracy, because once the records have been updated,the recall cannot be regenerated again.Printing the Recall ReportBefore printing the patient recall letters, the Recall Report must be printed to review patients thatare due to return for a mammogram and/or patients that do not have recall codes entered in theirmammogram record.· This report creates a file build on the terminal where it was printed and will be the basis for theletters, lists, and labels that will be printed as well as the update performed after the letters areprinted.Update Recall RecordThe Update Recall Record option will update the patient’s mammogram record included in thecurrent recall and record the technologist’s initials. Records are updated based on the informationgenerated for the Recall Report and the Repeat Recall Report. An Update Recall RecordReport is also generated to provide a record of the patients that were included in the currentrecall. It also includes the date, any comments that may have been added, and the initials of theperson that generated the report. After the update, the mammogram record is only used todocument recall information.When the patient comes in for the recall mammogram, a newmammogram record will be created. Update recall record must be executed after the recall filebuild and must be executed from the same terminal that generated the recall report. The UpdateRecall Record Report includes the following information:· Patient Name· Index Number· Account Number· Age· Sex· Referring Physician· Exam Date· Recall Code and Description· Recall Number· Date· Technologist Initials· CommentsThe Update Recall Record option will also allow the previous mammogram recall report generated© 2009 Computer Programs and Systems, Inc.

General Information 37from the terminal to be reprinted.2.5 Repeat Recall LettersRepeat Recall letters include the 2 nd and 3 rd notices sent to the patient informing them that theyare “delinquent” for their return mammogram. The 2 nd recall letter is sent when the patient isdelinquent at least 1 month. The 3 rd recall letter is sent when the patient is delinquent at least 2months and is usually sent by registered mail. Mailing labels can also be generated for the recallletters. The body and format of the letter are hospital defined, but will include:· Patient Name· Address· Previous Exam and Exam Date· Physician Name.Repeat Recall letters are usually generated at the beginning of the month, following the update ofthe recall letters.Several options exist for Recall letters.· A letter sent to the patient.· A letter sent to the physician.· A letter sent to both the patient and physician.· A copy of the patient’s recall letter and a list of all patients due to return can also be sent to thereferring physician with an accompanying cover letter. The list will include:• Patient’s Name• Index Number• Account Number• Age• Sex• Ordering Physician• Exam date• Recall code and description.This is controlled in the Physician Maintenance Table of the Business Office Tables and is basedon individual physician preferences.Repeat Recall Process OverviewThe Repeat Recall Process should be performed each month and always be performed after therecall process in the following order:1. Print the Repeat Recalls Report for the 2 nd Recall. – Review the report for patients withoutrecall codes. Add the appropriate recall codes if necessary and re-generate the report ifchanges have been made. This is important because the letters print based on the informationgenerated on the last report from that workstation.© 2009 Computer Programs and Systems, Inc.

38Mammography Workbook2. Print the Repeat Recalls Letters/Lists – Prints the patient letters and lists of patients due toreturn for the physicians (must be generated from the same workstation that generated theRecall Report).3. Print the patient address Labels – Prints patient address labels to be placed on recall letterenvelopes.4. Update – This updates the mammogram records with the technologist initials, date andcomments. This is applied to the recall page of the mammogram record. It is very importantthat the letters/lists are checked for accuracy, because once the records have been updated,the recall cannot be regenerated again.5. Repeat steps 1-4 for the 3 rd Recall.Printing the Repeat Recall ReportThe Repeat Recalls Report will include patients who have not responded to the original recallletter within a specified period of time. It will sort exam date followed by patient name. This reportcreates a file build on the terminal where it was generated for which the information for printingletters, lists, and labels is stored. Therefore, repeat recall letters, lists, and labels must begenerated from this terminal.The Update Recall Record must be executed from this sameterminal as well.Update Repeat Recall RecordThe Update Recall Record option will update the patient’s mammogram record included in thecurrent recall and record the technologist’s initials. Records are updated based on the informationgenerated for the Recall Report and the Repeat Recall Report. An Update Recall RecordReport is also generated to provide a record of the patients that were included in the currentrecall. It also includes the date, any comments that may have been added, and the initials of theperson that generated the report. After the update, the mammogram record is only used todocument recall information. When the patient comes in for the recall mammogram, a newmammogram record will be created. Update recall record must be executed after the recall filebuild and must be executed from the same terminal that generated the recall report. The UpdateRecall Record Report includes the following information:· Patient Name· Index Number· Account Number· Age· Sex· Referring Physician· Exam Date· Recall Code and Description© 2009 Computer Programs and Systems, Inc.

General Information 39· Recall Number· Date· Technologist Initials· CommentsThe Update Recall Record option will also allow the previous mammogram recall report generatedfrom the terminal to be reprinted.© 2009 Computer Programs and Systems, Inc.

40Mammography Workbook© 2009 Computer Programs and Systems, Inc.

Sample Letters 41Chapter 3Sample Letters3.1 OverviewThis Chapter will discuss and display sample letters that pertain to the Mammography application.3.2 Negative Notification Letters (BIRADS 1,2)February 21, 2007 1CPSI DEMO HOSPITAL6600 WALL STREETMOBILE, AL 36695BOLTZ CAROLYNRR 1 BOX 4266SARALAND, AL 3664223MAMMOGRAM BILATERAL2/20/074BAXTER JOHN MD 5Dear Patient,We are please to inform you that the results of your recent mammographyexamination are normal.As you know, early detection of cancer is very important. Althoughmammography is the most accurate method for early detection, not allcancers are found through mammography. A thorough examination includesa combination of mammography, physical examination and breastself-examination. Current American Cancer Society Guidelines recommendscreening mammograms and physical Examinations every year beginning atage 40.A report of your mammography results was sent to your physician.Your mammogram will become part if your medical file here at CPSI DemoHospital for at least 10 years. You are responsible for informing anynew health care provider or mammography facility of the date andlocation of this examination.Sincerely, Legend1. Date printedJane Brown, MD2. Facility Name and AddressInterpreting Radiologist3. Patient Name and Address4. Last Procedure and Date(334)639-8100 5. Referring PhysicianFigure 3.1 Negative Notification Letter Example© 2009 Computer Programs and Systems, Inc.

42Mammography Workbook3.3 Needs Additional Evaluation Notification Letter(BIRADS 0)February 21, 2007CPSI Demo Hospital6600 Wall StreetMobile, AL 36695BOLTZ CAROLYNRR 1 BOX 4266SARALAND, AL 36672MAMMOGRAM BILATERAL2/20/07BAXTER JOHN MDDear Patient:Your recent mammography examination showed a finding that requiresadditional imaging studies for a complete evaluation. Most suchfindings are benign (not cancer). Please call 334-639-8100 to schedulean appointment for these tests if you have not already done so.A report of your mammography results was sent to your referringphysician.Your mammogram will become part of your medical file here at CPSI DemoHospital for at least 10 years. You are responsible for informing anynew health care provider or mammography facility of the date andlocation of this examination.Sincerely,Jane Brown, MDInterpreting RadiologistFigure 3.2 Needs Additional Evaluation Notification Letter Example© 2009 Computer Programs and Systems, Inc.

Sample Letters 433.4 Probably Benign Notification Letter(BIRADS 3)February 21, 2007CPSI DEMO HOSPITAL6600 WALL STREETMOBILE, AL 36695BOLTZ CAROLYNRR 1 BOX 4266SARALANE, AL 36642MAMMOGRAM BILATERAL2/20/07BAXTER JOHN MDDear Patient:Your recent mammography examination showed an area that we believe isbenign (not cancer). However, in six months, you should have afollow-up mammogram to confirm that this area has not changed.As you know, early detection of cancer is very important. A thoroughexamination includes a combination of mammography, physical examinationand breast self-examination. Current American Cancer Society Guidelinesrecommend screening mammograms and physical breast examinations everyyear beginning at the age of 40.A report of your mammography results was sent to your referringphysician.Your mammogram will become part of your medical file here at CPSI DemoHospital for at least 10 years. You are responsible for informing anynew health care provider or mammography facility of the date andlocation of this examination.Sincerely,Jane Brown, MDInterpreting RadiologistFigure 3.3 Probably Benign Notification Letter Example© 2009 Computer Programs and Systems, Inc.

44Mammography Workbook3.5 3 Month Recall LetterCPSI DEMO HOSPITAL6600 WALL STREET 1MOBILE, AL 3669501/22/07 2CARRY ALLEN987 ROYAL STREET 3MOBILE, AL 36695MAMMOGRAM BILATERAL 410/03/06JAMES L BAXTER 5Dear Patient,The purpose of this letter is to remind you that it is time for your3 month mammogram. Please contact your physician's office to arrangean appointment.If you have already had your mammogram, please disregard this notice.Thank you,Radiology DepartmentCPSI DEMO HOSPITAL(334)639-8100Legend1-Facility Name and Address2-Date printed3-Patient Name and Address4-Last Procedure and Date5-Referring PhysicianFigure 3.4 3 Month Recall Letter Example© 2009 Computer Programs and Systems, Inc.

Sample Letters 453.6 1 Year Recall LetterCPSI DEMO HOSPITAL6600 WALL STREETMOBILE, AL 3669501/22/07AMY STEPHENS1220 DOMINION DRIVE WESTMOBILE, AL 36695MAMMOGRAM BILATERAL1/01/06JAMES L BAXTERDear Patient,The purpose of this letter is to remind you that it is time for youryearly mammogram. Please contact your physician's office to arrangean appointment.If you have already had your mammogram, please disregard this notice.Thank you,Radiology DepartmentCPSI DEMO HOSPITAL(334)639-8100Figure 3.5 1 Year Recall Letter Example© 2009 Computer Programs and Systems, Inc.

46Mammography Workbook3.7 Repeat Recall LetterCPSI DEMO HOSPITAL6600 WALL STREETMOBILE, AL 3669501/24/07STEPHANIE JANOWSKI1200 DOMINION DRIVE WESTMOBILE, AL 36695MAMMOGRAM BILATERAL04/19/06BAXTER JAMES LDear Patient,According to our records, you did not return for your mammogram. If youwouldlike to set up an appointment, please contact your physician's office.If youhave received your mammogram at another facility, please contact us sothat we can update our records.This is to serve as your third and final notice.Thank you,Radiology DepartmentCPSI DEMO HOSPITAL(334)639-8100Figure 3.6 Repeat Recall Letter Example© 2009 Computer Programs and Systems, Inc.

Sample Letters 473.8 Recall Letter/List - Physician Cover Letter/ListJanuary 22, 2007JAMES L BAXTER2121 CANDLE LANEMOBILE, AL 36695Dear JAMES L BAXTER,Enclosed you will find a list of your patients who are due for theirmammogram. We have also attached letters that you may keep as records.Wehave sent each patient a notice letter as well. Please contact ourofficeif patients have had mammograms performed at another facility or toscheduleappointments.Thank you,Radiology DepartmentCPSI DEMO HOSPITAL(334)639-8100Figure 3.7 Physician Recall Cover Letter/ListRUN DATE: 01/22/01 CPSI DEMO HOSPITAL PAGE 1TIME: 13:05MAMMOGRAPHY RECALL REPORTOXRMAMLTRRECALL PERIOD: 01/01/01 - 01/31/01LIST FOR: BAXTER JAMES LRECALL PATIENT LIST:NAME INDEX # ACCT # AGE SEX PHYSICIAN EXAM-DT CODEDESCRIPTIONSTEPHENS AMY 986574 101737 42 F BAXTER JAMES L 1/01/00 1YR 1 YR RECALLSIMS PAT 986555 245337 45 F BAXTER JAMES L 1/02/00 1YR 1 YR RECALLALLEN CARRY 124777 724922 32 F BAXTER JAMES L 10/03/00 3M 3 MONTHFUPFigure 3.8 Physician Recall List© 2009 Computer Programs and Systems, Inc.

48Mammography Workbook3.9 Repeat Recall Letter/List - Physician Cover Letter/ListJanuary 24, 2007BRADFORD RICHARD2121 CANDLE LANEMOBILE, AL 36695Dear RICHARD BRADFORD,Enclosed you will find a list of your patients who are over due fortheirmammogram. We have also attached letters that you may keep as records.Wehave sent each patient a notice letter as well. Please contact ourofficeif patients have had mammograms performed at another facility or toscheduleappointments.Thank you,Radiology DepartmentCPSI DEMO HOSPITAL(334)639-8100Figure 3.9 Physician Repeat Recall Cover LetterRUN DATE: 01/24/01 CPSI DEMO HOSPITAL PAGE1TIME: 11:25MAMMOGRAPHY REPEAT RECALL REPORTOXRMAMRRLTLIST FOR: BREDFORD RICHARDREPEAT RECALL PATIENT LIST:NAME INDEX #ACCT # AGE SEX PHYSICIAN EXAM-DT CODE DESCRIPTIONSMITH JANE 234587 700704 26 F BRADFORD RICHARD 7/02/00 3MTH 3 MONTHSRECALL #1: 10/02/00 by YYY COMMENTS:RECALL #2: 10/02/00 by YYY COMMENTS:Figure 3.10 Physician Repeat Recall List© 2009 Computer Programs and Systems, Inc.

Sample Reports 49Chapter 4Sample Reports4.1 OverviewThis Chapter will give examples of various sample mammography reports.4.2 Mammo Data ReportsThe CPSI Mammography Application offers a variety of Mammo Data Reports including:· Patient Data Records: Provides the department with a hard copy of the patient’smammography record.· Mammo Data Records: Provides a list of the status of the mammography record types forpatients within the specified date range.· Physician Mammo Usage: Provides a tracking mechanism for the number of proceduresreferred by each physician as well as department totals.· Positive Mammogram Follow-up: Provides a list of all mammogram records with anassessment code of P, M or S that have a scheduled exam date within the specified date range.· Breast Ultrasounds: Provides a list of all patients who have received breast ultrasounds withinthe specified date range.· Mammography Database: Provides a mechanism to retrieve data from patient mammogramrecords and create a variety of ‘ad hoc’ mammogram reports.© 2009 Computer Programs and Systems, Inc.

50Mammography WorkbookMammo Patient Data RecordsFigure 4.1 Mammo Patient Data ReportsMammo Records ReportFigure 4.2 Mammo Data Records© 2009 Computer Programs and Systems, Inc.

Sample Reports 51Mammograpy Activity/Physician Usage ReportPositive Mammogram Follow Up ReportFigure 4.3 Mammo Physician Usage ReportBreast Ultrasound ReportFigure 4.4 Positive Mammogram ReportFigure 4.5 Breast Ultrasound Report© 2009 Computer Programs and Systems, Inc.

52Mammography WorkbookMammography Database ReportThe Mammography database is a powerful tool that provides a mechanism where ad hoc reportscan be created to gather statistical and demographic information. A sample report is included onthe next page. This report is an example of the type of information that can be pulled from patientrecords to monitor the receipt of old films.Information Needed: A report that lists· All patients in a given date range that had mammograms· Patient account number, medical record number, film number and exam date· Whether or not “Old films” field under Additional Evaluation had been indicated· Whether or not films had been received and the date they were received.Figure 4.6 Mammo Database© 2009 Computer Programs and Systems, Inc.

Sample Reports 534.3 Mammo QA ReportsThe following Mammo QA Reports are available:· QA Summary: Provides mammogram totals, averages and percentages, as well asassessment codes and findings for each radiologist.· Pathology Summary: Provides totals, averages and percentages for biopsies recommendedand performed. In addition, this report includes the type, size and stage of cancer found, typeof high-risk lesion found and benign findings.· Patient Profile Statistics: Provides totals and percentages of patients with cancer in variouscategories.The QA Summary provides interpretive data regarding the mammography records.Thecalculations and interpretations are described below.Resolved Findings: Mammography records which have a determination in the True/FalsePos/Neg field.Screening Mammograms: Mammography records which have “N” in the Palpable Finding and“N” in the Clinical Symptoms fields in the Patient Data record.Palpable Cancers Prospective: Mammography records which have “Y” in the Palpable Findingfield in the Patient Data record and have a Pathology Findings that are classified as “C” forcancer.Palpable Cancers Retrospective: Mammography records which have “N” in the PalpableFinding field of the Patient Data record, have Pathology Findings classified as “C” and in theFindings have Palpable Cancer “Y”.Number of Benign, Cysts, High Risk Lesions, or Cancers Diagnoses: These fields are talliedaccording to the classification code assigned to the Pathology Finding. Codes are listed belowand any finding coded “C” is further categorized as invasive or non-invasive:C-CancerL-High Risk LesionY-Cyst (Benign)B-Benign, other than CystN-No finding, patient did not return for recommended follow-up.Patients Assessed as “N”, “B”, “P”, “S”, “M”, “X”, “0 (zero)”: These fields are talliedaccording to the classification code assigned to the Radiologist Assessment. Codes are listedbelow and any assessment coded “P” is further categorized as either negative or unresolved.N-NegativeB-Benign Finding – NegativeP-Probably Benign Finding – Short Interval Follow-up SuggestedS-Suspicious Abnormality – Biopsy Should Be ConsideredM-Highly Suggestive of Malignancy – Appropriate Action Should be TakenX-Unresolved – Additional Patient Data not Obtained.0 (zero) – Need Additional Imaging Evaluation© 2009 Computer Programs and Systems, Inc.

54Mammography WorkbookTrue/False Pos/Neg: The facility may choose to assign the interpretation or to have the systemevaluate data and predict the interpretation. System determinations are explained below.True Positive: (includes all of the following criteria)· Pathology Findings of “C” Cancer· Mammogram Assessment of “S” Suspicious or “M” Highly suggestive of Malignancy· Palpable Finding blank in Patient Data Record· Palpable Cancer blank in Findings categoryTrue Positive Non-Palpable: (includes all of the following criteria)· Pathology Findings of “C” Cancer· Mammogram Assessment of “S” Suspicious of “M” Highly suggestive of Malignancy· Palpable Finding “N” in Patient Data Record· Palpable Cancer “N” in Findings categoryTrue Positive Palpable Prospective: (includes all of the following criteria)· Pathology Findings of “C” Cancer· Mammogram Assessment of “S” Suspicious or “M” Highly suggestive of Malignancy· Palpable Finding “Y” in Patient Data RecordTrue Positive Palpable Retrospective: (includes all of the following criteria)· Pathology Findings of “C” Cancer· Mammogram Assessment of “S” Suspicious or “M” Highly suggestive of Malignancy· Palpable Finding “N” in the Patient Data Record· Palpable Cancer “Y” in Findings categoryTrue Positive (IN SCREENING SETTING)· Clinical Symptoms “N” in the Patient Profile Data· Assessment code of “0” (zero) in the Exam Data© 2009 Computer Programs and Systems, Inc.

Sample Reports 55· Cancer Found Later “Y” in Findings categoryFalse Positive: (includes all of the following criteria)· Mammogram Assessment of “N” Negative, “B” Benign, or “P” Probably Benign· Additional Evaluation Recommendations are “Y” for Ultrasound or Additional Views,· Biopsy is “N”· Pathology Findings are blankFalse Positive Screening: (includes all of the following criteria)· Mammogram Assessment of “N” Negative, “B” Benign, or “P” Probably Benign· Clinical Symptoms field of Patient Data is “N”· Additional Evaluation Recommendations are “Y” for Ultrasound or Additional Views,· Biopsy is “N”· Pathology Findings are blankFalse Positive Biopsy: (includes all of the following criteria)· Pathology Findings of “L” High Risk Lesion, “Y” Benign Cyst, or “B” Benign other than Cyst· Additional Evaluation Recommendations are “Y” for Cyst Aspiration or Biopsy.False Positive (IN SCREENING SETTING)· Clinical Symptoms “N” in the Patient Profile Data· Assessment code of “0” (zero) in the Exam Data· Cancer Found Later “N” in Findings categoryTrue Negative: (includes all of the following criteria)· Mammogram Assessment of “N” Negative, B Benign, or “P” Probably Benign· no Additional Evaluation Recommendations· no Pathology Findings· Cancer Found Later is “N” or blank© 2009 Computer Programs and Systems, Inc.

56Mammography WorkbookFalse Negative: (includes all of the following criteria)· Mammogram Assessment of “N” Negative, “B” Benign, or “P” Probably Benign· Cancer Found Later is “Y”Positive Predictive Value for “S”: The total number of mammography records withmammogram assessment is “S” divided by the number of mammography records with PathologyFinding “C” multiplied by 100.Positive Predictive Value for “M”: The total number of mammogram records with mammogramassessment is “M” divided by the number of mammography records with Pathology Finding “C”multiplied by 100.Negative Predictive Value: The number of mammography records categorized as “TrueNegative” divided by the total “True Negatives” plus “False Positives” multiplied by 100.Sensitivity: The number of mammography records categorized as “True Positive” divided by thetotal of “False Negative” records multiplied by 100.Specificity: The number of mammography records categorized as “True Negative” divided bythe total of “False Positive” records multiplied by 100.© 2009 Computer Programs and Systems, Inc.

Sample Reports 57QA Summary All MammogramsRUN DATE: 03/20/07 CPSI DEMO HOSPITAL PAGE 1TIME: 15:59 MAMMOGRAPHY QA SUMMARY - ALL OXRMAMQASFROM: 2/01/07 THRU: 2/28/07 (1 MONTHS)INDICATOR NUMBER AVG/MO %--------------------------------------------------------------------------------------------------------------------------------TOTAL MAMMOGRAMS......................................................................................... 11 11.0 100.0TOTAL RESOLVED FINDINGS.................................................................................. 9 9.0 81.8TOTAL UNRESOLVED FINDINGS................................................................................ 2 2.0 18.2*NOTE: The following statistics are based upon resolved findings only.SCREENING MAMMOGRAMS..................................................................................... 5 5.0 55.6NON-SCREENING MAMMOGRAMS (MAMMOS DONE BECAUSE OF CLINICAL FINDINGS)...................................... 1 1.0 11.1PATIENTS ASSESSED AS "0" - NEED ADDITIONAL IMAGING EVALUATION............................................ 2 2.0 22.2PATIENTS ASSESSED AS "N" - NEGATIVE...................................................................... 0 0.0 .0PATIENTS ASSESSED AS "B" - BENIGN FINDING - NEGATIVE..................................................... 3 3.0 33.3PATIENTS ASSESSED AS "P" - PROBABLE BENIGN FINDING - SHORT INTERVAL FOLLOW-UP SUGGESTED.................. 1 1.0 11.1PATIENTS ASSESSED AS "S" - SUSPICIOUS ABNORMALITY - BIOPSY SHOULD BE CONSIDERED.......................... 2 2.0 22.2PATIENTS ASSESSED AS "M" - HIGHLY SUGGESTIVE OF MALIGANCY - APPROPRIATE ACTION SHOULD BE TAKEN........... 1 1.0 11.1NUMBER FOR WHOM ADDITIONAL IMAGING REQUESTED (EXTRA VIEW, ULTRASOUND), IN THE SCREENING SETTING)......... 3 3.0 33.3NUMBER WHO ACTUALLY RETURN FOR ADDITIONAL IMAGING AFTER INITIAL EVALUATION.......................... 3 3.0 33.3NUMBER WHO RETURN FOR ADDITIONAL IMAGING WHO ARE NEGATIVE........................................... 0 0.0 .0NUMBER WHO RETURN FOR ADDITIONAL IMAGING FOR WHOM A SHORT INTERVAL FOLLOW-UP IS RECOMMENDED......... 0 0.0 .0NUMBER WHO RETURN FOR ADDITIONAL IMAGING FOR WHOM A BIOPSY IS RECOMMENDED........................... 3 3.0 33.3NUMBER FOR WHOM A SHORT TERM FOLLOW-UP IS RECOMMENDED.................................................... 1 1.0 11.1NUMBER UNDERGOING FNA OR BIOPSY.......................................................................... 5 5.0 55.6NUMBER OF BENIGN FINDINGS OTHER THAN CYST DIAGNOSED...................................................... 3 3.0 33.3NUMBER OF CYSTS DIAGNOSED................................................................................ 0 0.0 .0NUMBER OF HIGH RISK LESIONS DIAGNOSED.................................................................... 1 1.0 11.1NUMBER OF CANCERS DIAGNOSED.............................................................................. 3 3.0 33.3NUMBER OF PALPABLE CANCERS - PROSPECTIVE, REFERRED WITH CLINICAL ABNORMALITY............................. 0 0.0 .0NUMBER OF PALPABLE CANCERS - RETROSPECTIVE AFTER MAMMOGRAPHY............................................. 1 1.0 11.1INTERVAL CANCERS (DIAGNOSED BETWEEN SCREEN - IF KNOWN)................................................... 0 0.0 .0TRUE POSITIVE FINDINGS - TOTAL........................................................................... 2 2.0 22.2TRUE POSITIVE FINDINGS - PALPABLE, TOTAL................................................................. 1 1.0 11.1TRUE POSITIVE FINDINGS - PALPABLE PROSPECTIVE TO MAMMOGRAM............................................... 0 0.0 .0TRUE POSITIVE FINDINGS - PALPABLE ONLY RETROSPECTIVE TO MAMMOGRAM........................................ 1 1.0 11.1FALSE POSITIVE FINDINGS - TOTAL.......................................................................... 4 4.0 44.4FALSE POSITIVE FINDINGS - SCREENING...................................................................... 0 0.0 .0FALSE POSITIVE FINDINGS - BIOPSY......................................................................... 2 2.0 22.2TRUE NEGATIVE FINDINGS................................................................................... 2 2.0 22.2FALSE NEGATIVE FINDINGS.................................................................................. 0 0.0 .0POSITIVE PREDICTIVE VALUE - ABNORMAL FINDINGS AT SCREENING............................................................... 50.0POSITIVE PREDICTIVE VALUE - BIOPSY RECOMMENDED........................................................................... 66.6POSITIVE PREDICTIVE VALUE - BIOPSY PERFORMED............................................................................. 66.6NEGATIVE PREDICTIVE VALUE................................................................................................ 100.0SENSITIVITY.............................................................................................................. 100.0SPECIFICITY.............................................................................................................. 33.3ACCURACY.......................................................................................................... . 44.4Figure 4.7 QA Summary(All Mammograms)© 2009 Computer Programs and Systems, Inc.

58Mammography WorkbookQA Summary All ScreeningRUN DATE: 03/20/07 CPSI DEMO HOSPITAL PAGE 2TIME: 15:59 MAMMOGRAPHY QA SUMMARY - ALL (SCREENING) OXRMAMQASFROM: 2/01/07 THRU: 2/28/07 (1 MONTHS)INDICATOR NUMBER AVG/MO %--------------------------------------------------------------------------------------------------------------------------------TOTAL MAMMOGRAMS......................................................................................... 7 7.0 100.0TOTAL RESOLVED FINDINGS.................................................................................. 5 5.0 71.4TOTAL UNRESOLVED FINDINGS................................................................................ 2 2.0 28.6*NOTE: The following statistics are based upon resolved findings only.SCREENING MAMMOGRAMS..................................................................................... 5 5.0 100.0NON-SCREENING MAMMOGRAMS (MAMMOS DONE BECAUSE OF CLINICAL FINDINGS)...................................... 0 0.0 .0PATIENTS ASSESSED AS "0" - NEED ADDITIONAL IMAGING EVALUATION............................................ 1 1.0 20.0PATIENTS ASSESSED AS "N" - NEGATIVE...................................................................... 0 0.0 .0PATIENTS ASSESSED AS "B" - BENIGN FINDING - NEGATIVE..................................................... 1 1.0 20.0PATIENTS ASSESSED AS "P" - PROBABLE BENIGN FINDING - SHORT INTERVAL FOLLOW-UP SUGGESTED.................. 0 0.0 .0PATIENTS ASSESSED AS "S" - SUSPICIOUS ABNORMALITY - BIOPSY SHOULD BE CONSIDERED.......................... 2 2.0 40.0PATIENTS ASSESSED AS "M" - HIGHLY SUGGESTIVE OF MALIGANCY - APPROPRIATE ACTION SHOULD BE TAKEN........... 1 1.0 20.0NUMBER FOR WHOM ADDITIONAL IMAGING REQUESTED (EXTRA VIEW, ULTRASOUND), IN THE SCREENING SETTING)......... 3 3.0 60.0NUMBER WHO ACTUALLY RETURN FOR ADDITIONAL IMAGING AFTER INITIAL EVALUATION.......................... 3 3.0 60.0NUMBER WHO RETURN FOR ADDITIONAL IMAGING WHO ARE NEGATIVE........................................... 0 0.0 .0NUMBER WHO RETURN FOR ADDITIONAL IMAGING FOR WHOM A SHORT INTERVAL FOLLOW-UP IS RECOMMENDED......... 0 0.0 .0NUMBER WHO RETURN FOR ADDITIONAL IMAGING FOR WHOM A BIOPSY IS RECOMMENDED........................... 3 3.0 60.0NUMBER FOR WHOM A SHORT TERM FOLLOW-UP IS RECOMMENDED.................................................... 0 0.0 .0NUMBER UNDERGOING FNA OR BIOPSY.......................................................................... 4 4.0 80.0NUMBER OF BENIGN FINDINGS OTHER THAN CYST DIAGNOSED...................................................... 0 0.0 .0NUMBER OF CYSTS DIAGNOSED................................................................................ 0 0.0 .0NUMBER OF HIGH RISK LESIONS DIAGNOSED.................................................................... 1 1.0 20.0NUMBER OF CANCERS DIAGNOSED.............................................................................. 3 3.0 60.0NUMBER OF PALPABLE CANCERS - PROSPECTIVE, REFERRED WITH CLINICAL ABNORMALITY............................. 0 0.0 .0NUMBER OF PALPABLE CANCERS - RETROSPECTIVE AFTER MAMMOGRAPHY............................................. 1 1.0 20.0INTERVAL CANCERS (DIAGNOSED BETWEEN SCREEN - IF KNOWN)................................................... 0 0.0 .0TRUE POSITIVE FINDINGS - TOTAL........................................................................... 2 2.0 40.0TRUE POSITIVE FINDINGS - PALPABLE, TOTAL................................................................. 1 1.0 20.0TRUE POSITIVE FINDINGS - PALPABLE PROSPECTIVE TO MAMMOGRAM............................................... 0 0.0 .0TRUE POSITIVE FINDINGS - PALPABLE ONLY RETROSPECTIVE TO MAMMOGRAM........................................ 1 1.0 20.0FALSE POSITIVE FINDINGS - TOTAL.......................................................................... 1 1.0 20.0FALSE POSITIVE FINDINGS - SCREENING...................................................................... 0 0.0 .0FALSE POSITIVE FINDINGS - BIOPSY......................................................................... 1 1.0 20.0TRUE NEGATIVE FINDINGS................................................................................... 1 1.0 20.0FALSE NEGATIVE FINDINGS.................................................................................. 0 0.0 .0POSITIVE PREDICTIVE VALUE - ABNORMAL FINDINGS AT SCREENING............................................................... 50.0POSITIVE PREDICTIVE VALUE - BIOPSY RECOMMENDED........................................................................... 66.6POSITIVE PREDICTIVE VALUE - BIOPSY PERFORMED............................................................................. 66.6NEGATIVE PREDICTIVE VALUE................................................................................................ 100.0SENSITIVITY.............................................................................................................. 100.0SPECIFICITY.............................................................................................................. 50.0ACCURACY................................................................................................................. 60.0Figure 4.8 QA Summary (All Screening)© 2009 Computer Programs and Systems, Inc.

Sample Reports 59QA Summary All Non-ScreeningRUN DATE: 03/20/07 CPSI DEMO HOSPITAL PAGE 3TIME: 15:59 MAMMOGRAPHY QA SUMMARY - ALL (NON-SCREENING) OXRMAMQASFROM: 2/01/07 THRU: 2/28/07 (1 MONTHS)INDICATOR NUMBER AVG/MO %--------------------------------------------------------------------------------------------------------------------------------TOTAL MAMMOGRAMS......................................................................................... 1 1.0 100.0TOTAL RESOLVED FINDINGS.................................................................................. 1 1.0 100.0TOTAL UNRESOLVED FINDINGS................................................................................ 0 0.0 .0*NOTE: The following statistics are based upon resolved findings only.SCREENING MAMMOGRAMS..................................................................................... 0 0.0 .0NON-SCREENING MAMMOGRAMS (MAMMOS DONE BECAUSE OF CLINICAL FINDINGS)...................................... 1 1.0 100.0PATIENTS ASSESSED AS "0" - NEED ADDITIONAL IMAGING EVALUATION............................................ 1 1.0 100.0PATIENTS ASSESSED AS "N" - NEGATIVE...................................................................... 0 0.0 .0PATIENTS ASSESSED AS "B" - BENIGN FINDING - NEGATIVE..................................................... 0 0.0 .0PATIENTS ASSESSED AS "P" - PROBABLE BENIGN FINDING - SHORT INTERVAL FOLLOW-UP SUGGESTED.................. 0 0.0 .0PATIENTS ASSESSED AS "S" - SUSPICIOUS ABNORMALITY - BIOPSY SHOULD BE CONSIDERED.......................... 0 0.0 .0PATIENTS ASSESSED AS "M" - HIGHLY SUGGESTIVE OF MALIGANCY - APPROPRIATE ACTION SHOULD BE TAKEN........... 0 0.0 .0NUMBER FOR WHOM ADDITIONAL IMAGING REQUESTED (EXTRA VIEW, ULTRASOUND), IN THE SCREENING SETTING)......... 0 0.0 .0NUMBER WHO ACTUALLY RETURN FOR ADDITIONAL IMAGING AFTER INITIAL EVALUATION.......................... 0 0.0 .0NUMBER WHO RETURN FOR ADDITIONAL IMAGING WHO ARE NEGATIVE........................................... 0 0.0 .0NUMBER WHO RETURN FOR ADDITIONAL IMAGING FOR WHOM A SHORT INTERVAL FOLLOW-UP IS RECOMMENDED......... 0 0.0 .0NUMBER WHO RETURN FOR ADDITIONAL IMAGING FOR WHOM A BIOPSY IS RECOMMENDED........................... 0 0.0 .0NUMBER FOR WHOM A SHORT TERM FOLLOW-UP IS RECOMMENDED.................................................... 0 0.0 .0NUMBER UNDERGOING FNA OR BIOPSY.......................................................................... 1 1.0 100.0NUMBER OF BENIGN FINDINGS OTHER THAN CYST DIAGNOSED...................................................... 1 1.0 100.0NUMBER OF CYSTS DIAGNOSED................................................................................ 0 0.0 .0NUMBER OF HIGH RISK LESIONS DIAGNOSED.................................................................... 0 0.0 .0NUMBER OF CANCERS DIAGNOSED.............................................................................. 0 0.0 .0NUMBER OF PALPABLE CANCERS - PROSPECTIVE, REFERRED WITH CLINICAL ABNORMALITY............................. 0 0.0 .0NUMBER OF PALPABLE CANCERS - RETROSPECTIVE AFTER MAMMOGRAPHY............................................. 0 0.0 .0INTERVAL CANCERS (DIAGNOSED BETWEEN SCREEN - IF KNOWN)................................................... 0 0.0 .0TRUE POSITIVE FINDINGS - TOTAL........................................................................... 0 0.0 .0TRUE POSITIVE FINDINGS - PALPABLE, TOTAL................................................................. 0 0.0 .0TRUE POSITIVE FINDINGS - PALPABLE PROSPECTIVE TO MAMMOGRAM............................................... 0 0.0 .0TRUE POSITIVE FINDINGS - PALPABLE ONLY RETROSPECTIVE TO MAMMOGRAM........................................ 0 0.0 .0FALSE POSITIVE FINDINGS - TOTAL.......................................................................... 1 1.0 100.0FALSE POSITIVE FINDINGS - SCREENING...................................................................... 0 0.0 .0FALSE POSITIVE FINDINGS - BIOPSY......................................................................... 1 1.0 100.0TRUE NEGATIVE FINDINGS................................................................................... 0 0.0 .0FALSE NEGATIVE FINDINGS.................................................................................. 0 0.0 .0POSITIVE PREDICTIVE VALUE - ABNORMAL FINDINGS AT SCREENING............................................................... .0POSITIVE PREDICTIVE VALUE - BIOPSY RECOMMENDED........................................................................... .0POSITIVE PREDICTIVE VALUE - BIOPSY PERFORMED............................................................................. .0NEGATIVE PREDICTIVE VALUE................................................................................................ .0SENSITIVITY.............................................................................................................. .0SPECIFICITY.............................................................................................................. .0ACCURACY................................................................................................................. .0Figure 4.9 QA Summary All Non Screening© 2009 Computer Programs and Systems, Inc.

60Mammography WorkbookQA Summary All Screening and Non-ScreeningRUN DATE: 03/20/07 CPSI DEMO HOSPITAL PAGE 4TIME: 15:59 MAMMOGRAPHY QA SUMMARY - ALL (SCRN'G & NON-SCRN'G) OXRMAMQASFROM: 2/01/07 THRU: 2/28/07 (1 MONTHS)INDICATOR NUMBER AVG/MO %--------------------------------------------------------------------------------------------------------------------------------TOTAL MAMMOGRAMS......................................................................................... 8 8.0 100.0TOTAL RESOLVED FINDINGS.................................................................................. 6 6.0 75.0TOTAL UNRESOLVED FINDINGS................................................................................ 2 2.0 25.0*NOTE: The following statistics are based upon resolved findings only.SCREENING MAMMOGRAMS..................................................................................... 5 5.0 83.3NON-SCREENING MAMMOGRAMS (MAMMOS DONE BECAUSE OF CLINICAL FINDINGS)...................................... 1 1.0 16.7PATIENTS ASSESSED AS "0" - NEED ADDITIONAL IMAGING EVALUATION............................................ 2 2.0 33.3PATIENTS ASSESSED AS "N" - NEGATIVE...................................................................... 0 0.0 .0PATIENTS ASSESSED AS "B" - BENIGN FINDING - NEGATIVE..................................................... 1 1.0 16.7PATIENTS ASSESSED AS "P" - PROBABLE BENIGN FINDING - SHORT INTERVAL FOLLOW-UP SUGGESTED.................. 0 0.0 .0PATIENTS ASSESSED AS "S" - SUSPICIOUS ABNORMALITY - BIOPSY SHOULD BE CONSIDERED.......................... 2 2.0 33.3PATIENTS ASSESSED AS "M" - HIGHLY SUGGESTIVE OF MALIGANCY - APPROPRIATE ACTION SHOULD BE TAKEN........... 1 1.0 16.7NUMBER FOR WHOM ADDITIONAL IMAGING REQUESTED (EXTRA VIEW, ULTRASOUND), IN THE SCREENING SETTING)......... 3 3.0 50.0NUMBER WHO ACTUALLY RETURN FOR ADDITIONAL IMAGING AFTER INITIAL EVALUATION.......................... 3 3.0 50.0NUMBER WHO RETURN FOR ADDITIONAL IMAGING WHO ARE NEGATIVE........................................... 0 0.0 .0NUMBER WHO RETURN FOR ADDITIONAL IMAGING FOR WHOM A SHORT INTERVAL FOLLOW-UP IS RECOMMENDED......... 0 0.0 .0NUMBER WHO RETURN FOR ADDITIONAL IMAGING FOR WHOM A BIOPSY IS RECOMMENDED........................... 3 3.0 50.0NUMBER FOR WHOM A SHORT TERM FOLLOW-UP IS RECOMMENDED.................................................... 0 0.0 .0NUMBER UNDERGOING FNA OR BIOPSY.......................................................................... 5 5.0 83.3NUMBER OF BENIGN FINDINGS OTHER THAN CYST DIAGNOSED...................................................... 1 1.0 16.7NUMBER OF CYSTS DIAGNOSED................................................................................ 0 0.0 .0NUMBER OF HIGH RISK LESIONS DIAGNOSED.................................................................... 1 1.0 16.7NUMBER OF CANCERS DIAGNOSED.............................................................................. 3 3.0 50.0NUMBER OF PALPABLE CANCERS - PROSPECTIVE, REFERRED WITH CLINICAL ABNORMALITY............................. 0 0.0 .0NUMBER OF PALPABLE CANCERS - RETROSPECTIVE AFTER MAMMOGRAPHY............................................. 1 1.0 16.7INTERVAL CANCERS (DIAGNOSED BETWEEN SCREEN - IF KNOWN)................................................... 0 0.0 .0TRUE POSITIVE FINDINGS - TOTAL........................................................................... 2 2.0 33.3TRUE POSITIVE FINDINGS - PALPABLE, TOTAL................................................................. 1 1.0 16.7TRUE POSITIVE FINDINGS - PALPABLE PROSPECTIVE TO MAMMOGRAM............................................... 0 0.0 .0TRUE POSITIVE FINDINGS - PALPABLE ONLY RETROSPECTIVE TO MAMMOGRAM........................................ 1 1.0 16.7FALSE POSITIVE FINDINGS - TOTAL.......................................................................... 2 2.0 33.3FALSE POSITIVE FINDINGS - SCREENING...................................................................... 0 0.0 .0FALSE POSITIVE FINDINGS - BIOPSY......................................................................... 2 2.0 33.3TRUE NEGATIVE FINDINGS................................................................................... 1 1.0 16.7FALSE NEGATIVE FINDINGS.................................................................................. 0 0.0 .0POSITIVE PREDICTIVE VALUE - ABNORMAL FINDINGS AT SCREENING............................................................... 50.0POSITIVE PREDICTIVE VALUE - BIOPSY RECOMMENDED........................................................................... 66.6POSITIVE PREDICTIVE VALUE - BIOPSY PERFORMED............................................................................. 66.6NEGATIVE PREDICTIVE VALUE................................................................................................ 100.0SENSITIVITY.............................................................................................................. 100.0SPECIFICITY.............................................................................................................. 33.3ACCURACY................................................................................................................. 50.0Figure 4.10 QA Summary All Screening and Non ScreeningQA Summary Mammograms per RadiologistRUN DATE: 03/20/07 CPSI DEMO HOSPITAL PAGE 22TIME: 15:59 MAMMOGRAPHY QA SUMMARY - RLR OXRMAMQASFROM: 2/01/07 THRU: 2/28/07 (1 MONTHS)INDICATOR NUMBER AVG/MO %--------------------------------------------------------------------------------------------------------------------------------TOTAL MAMMOGRAMS......................................................................................... 1 1.0 100.0TOTAL RESOLVED FINDINGS.................................................................................. 1 1.0 100.0TOTAL UNRESOLVED FINDINGS................................................................................ 0 0.0 .0*NOTE: The following statistics are based upon resolved findings only.SCREENING MAMMOGRAMS..................................................................................... 1 1.0 100.0NON-SCREENING MAMMOGRAMS (MAMMOS DONE BECAUSE OF CLINICAL FINDINGS)...................................... 0 0.0 .0PATIENTS ASSESSED AS "0" - NEED ADDITIONAL IMAGING EVALUATION............................................ 1 1.0 100.0PATIENTS ASSESSED AS "N" - NEGATIVE...................................................................... 0 0.0 .0PATIENTS ASSESSED AS "B" - BENIGN FINDING - NEGATIVE..................................................... 0 0.0 .0PATIENTS ASSESSED AS "P" - PROBABLE BENIGN FINDING - SHORT INTERVAL FOLLOW-UP SUGGESTED.................. 0 0.0 .0PATIENTS ASSESSED AS "S" - SUSPICIOUS ABNORMALITY - BIOPSY SHOULD BE CONSIDERED.......................... 0 0.0 .0PATIENTS ASSESSED AS "M" - HIGHLY SUGGESTIVE OF MALIGANCY - APPROPRIATE ACTION SHOULD BE TAKEN........... 0 0.0 .0NUMBER FOR WHOM ADDITIONAL IMAGING REQUESTED (EXTRA VIEW, ULTRASOUND), IN THE SCREENING SETTING)......... 1 1.0 100.0NUMBER WHO ACTUALLY RETURN FOR ADDITIONAL IMAGING AFTER INITIAL EVALUATION.......................... 1 1.0 100.0NUMBER WHO RETURN FOR ADDITIONAL IMAGING WHO ARE NEGATIVE........................................... 0 0.0 .0NUMBER WHO RETURN FOR ADDITIONAL IMAGING FOR WHOM A SHORT INTERVAL FOLLOW-UP IS RECOMMENDED......... 0 0.0 .0NUMBER WHO RETURN FOR ADDITIONAL IMAGING FOR WHOM A BIOPSY IS RECOMMENDED........................... 1 1.0 100.0NUMBER FOR WHOM A SHORT TERM FOLLOW-UP IS RECOMMENDED.................................................... 0 0.0 .0NUMBER UNDERGOING FNA OR BIOPSY.......................................................................... 1 1.0 100.0NUMBER OF BENIGN FINDINGS OTHER THAN CYST DIAGNOSED...................................................... 0 0.0 .0NUMBER OF CYSTS DIAGNOSED................................................................................ 0 0.0 .0NUMBER OF HIGH RISK LESIONS DIAGNOSED.................................................................... 0 0.0 .0NUMBER OF CANCERS DIAGNOSED.............................................................................. 1 1.0 100.0NUMBER OF PALPABLE CANCERS - PROSPECTIVE, REFERRED WITH CLINICAL ABNORMALITY............................. 0 0.0 .0NUMBER OF PALPABLE CANCERS - RETROSPECTIVE AFTER MAMMOGRAPHY............................................. 0 0.0 .0INTERVAL CANCERS (DIAGNOSED BETWEEN SCREEN - IF KNOWN)................................................... 0 0.0 .0TRUE POSITIVE FINDINGS - TOTAL........................................................................... 0 0.0 .0TRUE POSITIVE FINDINGS - PALPABLE, TOTAL................................................................. 0 0.0 .0TRUE POSITIVE FINDINGS - PALPABLE PROSPECTIVE TO MAMMOGRAM............................................... 0 0.0 .0TRUE POSITIVE FINDINGS - PALPABLE ONLY RETROSPECTIVE TO MAMMOGRAM........................................ 0 0.0 .0FALSE POSITIVE FINDINGS - TOTAL.......................................................................... 0 0.0 .0FALSE POSITIVE FINDINGS - SCREENING...................................................................... 0 0.0 .0FALSE POSITIVE FINDINGS - BIOPSY......................................................................... 0 0.0 .0TRUE NEGATIVE FINDINGS................................................................................... 0 0.0 .0FALSE NEGATIVE FINDINGS.................................................................................. 0 0.0 .0© 2009 Computer Programs and Systems, Inc.

Sample Reports 61POSITIVE PREDICTIVE VALUE - ABNORMAL FINDINGS AT SCREENING............................................................... .0POSITIVE PREDICTIVE VALUE - BIOPSY RECOMMENDED........................................................................... .0POSITIVE PREDICTIVE VALUE - BIOPSY PERFORMED............................................................................. .0NEGATIVE PREDICTIVE VALUE................................................................................................ .0SENSITIVITY.............................................................................................................. .0SPECIFICITY.............................................................................................................. .0ACCURACY................................................................................................................. .0Figure 4.12 QA Summary Mammogram Statistics Per Radiologist© 2009 Computer Programs and Systems, Inc.

62Mammography WorkbookQA Summary Mammograms per TechnologistFigure 4.11 Mammograms Per Technologist© 2009 Computer Programs and Systems, Inc.

Sample Reports 63Pathology Summary AllRUN DATE: 08/25/00 CPSI DEMO HOSPITAL PAGE 1 TIME:09:51 MAMMOGRAPHY PATHOLOGY SUMMARY - ALLOXRMAMPATH FROM: 8/01/00 THRU: 8/31/00 (1 MONTHS)GROUP: BIOPSIES RECOMMENDEDCODE INDICATOR NUMBER AVG/MO%--------------------------------------------------------------------------------------------------------------------------------TOTAL PATIENTS FOR WHOM FNA OR BIOPSY RECOMMENDED........................................................ 55.0 100.0TOTAL PATIENTS FOR WHOM FNA OR BIOPSY WAS PERFORMED................................................ 2 2.0 40.0NUMBER ASSESSED AS "S" - SUSPICIOUS ABNORMALITY - BIOPSY SHOULD BE CONSIDERED...................... 4 4.0 80.0NUMBER ASSESSED AS "M" - HIGHLY SUGGESTIVE OF MALIGNANCY - APPROPRIATE ACTION SHOULD BE TAKEN...... 1 1.0 20.0(*NOTE: All Subsequent statistics are based upon resolved findings only.)GROUP: BIOPSIES PERFORMEDCODE INDICATOR NUMBER AVG/MO%--------------------------------------------------------------------------------------------------------------------------------TOTAL PATIENTS FOR WHOM FNA OR BIOPSY WAS PERFORMED...................................................... 2 2.0 100.0NUMBER ASSESSED AS "S" - SUSPICIOUS ABNORMALITY - BIOPSY SHOULD BE CONSIDERED...................... 1 1.0 50.0NUMBER ASSESSED AS "M" - HIGHLY SUGGESTIVE OF MALIGNANCY - APPROPRIATE ACTION SHOULD BE TAKEN...... 1 1.0 50.0NUMBER WITH FINDINGS CLASSIFICATION "C" - CANCER................................................... 1 1.0 50.0Needle Biopsy...................................................................................... 1 1.0 50.0Sterotactic Biopsy................................................................................. 1 1.0 50.0NUMBER WITH FINDINGS CLASSIFICATION "B" - BENIGN (ANY OTHER BENIGN FINDING OTHER THAN A CYST)...... 1 1.0 50.0GROUP: CANCERS BY TYPECODE INDICATOR NUMBER AVG/MO%--------------------------------------------------------------------------------------------------------------------------------ALL CANCERS........................................................................................ 1 1.0 100.0NONINVASIVE CANCERS............................................................................ 1 1.0 100.0MALIG HIGHLY SUGGESTIVE OF MALIGNANCY.................................................................... 1 1.0 100.0GROUP: CANCERS BY SIZE (IN GREATEST DIMENSION)CODE INDICATOR NUMBER AVG/MO%--------------------------------------------------------------------------------------------------------------------------------ALL CANCERS........................................................................................ 1 1.0 100.0

64Mammography WorkbookPatient Profile StatisticsFigure 4.14 Patient Profile Statistics© 2009 Computer Programs and Systems, Inc.

Sample Reports 654.4 Mammo TablesThe Mammo Tables report provides the department with a hard copy of all codes and descriptionsdefined in the selected table.· All Tables: This option will print the table definitions of all Mammogram Tables.· Mass Shape: This option will print the mass shape codes and descriptions defined in the MassShape Code Table.· Mass Region: This option will print the mass region codes and descriptions defined in the MassRegion Code Table.· Mass Margins: This option will print the mass margin codes and descriptions defined in theMass Margins Code Table.· Mass Density Modifiers: This option will print the mass density modifier codes anddescriptions defined in the Mass Density Modifier Code Table.· Mass Calcification: This option will print the mass calcification codes and descriptions definedin the Mass Calcification Code Table.· Size Codes: This option will print the sort sequences, size codes and descriptions defined inthe Size Code Table.· Stage Codes: This option will print the sort sequence, stage codes and descriptions defined inthe Stage Code Table.· Age: Path/Profile Report: This option will print the sort sequence, beginning and ending age inyears, age codes and descriptions defined in the Age: Path/Profile Table.· Menarche Age: Profile Report: This option will print the sort sequence, beginning and endingage in years, menarche age codes and descriptions defined in the Menarche Age: Profile Table.· First Birth Age – Profile Report: This option will print the sort sequence, beginning and endingage in years, first birth age codes and descriptions defined in the First Birth Age: Profile Table.· True/False Pos/Neg Entries: This option will print the use of (Y or N), the True/False Pos/Negcodes and descriptions defined in the True/False Pos/Neg Table.· Technologist Initials: This option will print the technologist initials and names defined in theTechnologist Initials Table.· Biopsy Type Codes: This option will print the biopsy type codes and descriptions defined in theBiopsy Type Code Table.· Radiologist Initials: This option will print the radiologist initials and names defined in theRadiologist Initials Table.· Assessment Categories: This option will print the assessment codes and descriptions defined© 2009 Computer Programs and Systems, Inc.

66Mammography Workbookin the Assessment Categories Table.· Notification Code: This option will print the notification codes and descriptions defined in theNotification Code Table.· Recall Codes: This option will print the recall codes and descriptions including the number ofmonths and whether each code is considered short-term follow-up defined in the Recall CodeTable.· Findings Code: This option will print the findings codes and descriptions including theclassification and whether each code is considered invasive defined in the Findings Code Table.Mammo Tables Examples© 2009 Computer Programs and Systems, Inc.

Sample Reports 67Figure 4.15 Mammo Tables© 2009 Computer Programs and Systems, Inc.

68Mammography WorkbookFigure 4.16 Mammo Tables© 2009 Computer Programs and Systems, Inc.

Sample Reports 69Figure 4.17 Mammo Tables© 2009 Computer Programs and Systems, Inc.

70Mammography WorkbookFigure 4.18 Mammo Tables© 2009 Computer Programs and Systems, Inc.

Sample Reports 714.5 Cancer StatisticsThe number of cancers found for a specified date range per radiologist can be displayed and/orprinted via the following pathway. This data is determined based on the findings code of “C” in theMammography Findings page.1. From the Hospital Base Menu, select Department Specific.2. From the Ancillary Department Functions Menu, select Mammo System.3. The Number of Cancers Found screen will be displayed.· Enter the date range or All Dates for all cancers found.4. The following options may be selected at the command line:· Print to print the Number of Cancers Found report.Select Hospital Base Menu > Department Specific > Mammo System > Cancer StatisticsFigure 4.19 Cancer Statistics© 2009 Computer Programs and Systems, Inc.

72Mammography WorkbookChapter 5Questionnaire and Information Tables5.1 OverviewThis Chapter displays the questionnaire that is sent for sites to provide Mammography conversioninformation to CPSI5.2 Mammography Data General Information QuestionnaireInstructions: Please complete the following pages of information. Make copies of thecompleted information and return to CPSI.TASKDATE ACCOMPLISHEDDo you have a current computerized mammography system? If yes, _______what kind?Describe the current Mammography Data that is kept on each patient_______Describe what types of mammography statistics are kept. Please_______providesamplesWhat type of recall letters are sent from your facility, to whom, when arethey sent and why. Please provide copies of these letters._______Would you want to send a copy of the patient’s recall letter to thereferring_______physician or a list of all patients due for that physician?What type of repeat recall letters are sent from your facility? To whom,when andwhy are they sent? CPSI has capability of sending 1 st 2 nd and 3 rd Recall _______Letters. Please provide a copy of all three letters (if utilized).Would you want to send repeat recall letters to physicians that refermammogram_______patients or a list of those patients that did not return?What type of Notification letters are sent from your facility, to whom,when are they sent and why. Please provide copies of these letters.Note: Notification letters are sent notifying results of recent_______mammogram.Would you want to send notification letters to the referring physicians?_______© 2009 Computer Programs and Systems, Inc.

Questionnaire and Information Tables 73TASKDATE ACCOMPLISHEDThe CPSI system has the capability of sending Recall letters, Notificationletters, 2 nd Recall and 3 rd Recall letters to patients, referring physicians orboth. A Physician list may also be used either alone or with accompanyingrecall letters that will provide a list to the referring physician of his/herpatients that are due for their mammogram. Physician Cover letters for__________both Notification and Recall letters can also be printed for referringphysicians. Sample letters are included. If Physician cover letters aredesired, please provide copies of these letters.(one for recall and one fornotification). Please have Data Processing print a physician list for you.Please note the following by EACH physician that refers mammogrampatients to your facility:1) M – Refers Mammogram patients2) R – Wants copy of Recall letters3) L – Wants Physician list of recall patients4) RC – Wants Recall Cover Letter5) N – Wants copy of Notification Letters6) NC – Wants Notification Cover LetterWho currently transcribes mammogram reports?Does the radiologist dictate using BI-RADS codes?Do you want the transcriptionist to be prompted for any of the following? If Yes, Do you want thetranscriptionist to be prompted before or after transcription?Assessment Code:Notification Code:Recall Code:Y/NY/NY/N© 2009 Computer Programs and Systems, Inc.

74Mammography Workbook5.3 Mammography Data RecordsThe Mammography Application captures pertinent information regarding each patient encounter.The data captured is used to produce notification and recall letters and also contributes to avariety of statistical reports. Each facility determines the data to be captured. Please indicate thedata you would like to capture in each of the mammogram record categories.Menarche AgeAge at First BirthStill MenstruatingHysterectomyPast MenopauseFamily HistoryPalpable FindingsCommentsPatient on HormonesBreast CompositionPrior Breast SurgeryEXAM DATAType MammogramRead DateNotification CodeCommentsADDITIONAL EVALUATIONSAdditional ViewsUltrasoundAspiration in U/SU/S Guided BiopsyCyst AspirationOld Films Requested_______________________________________________________USE?____________________USE?______________________________© 2009 Computer Programs and Systems, Inc.

Questionnaire and Information Tables 75Magnification MammoSpot Compression__________Biopsy Recommended________________________________________________________________________________ADDITIONAL EVALUATIONS DATAAdditional ViewsUltrasoundAspiration in U/SU/S Guided BiopsyCyst AspirationOld Films RequestedMagnification MammoSpot CompressionUSE?________________________________________Biopsy Recommended_______________________________________________________________________________FINDINGSPalpable CancerSizeStageCancer found laterBiopsy TypeUSE?_________________________Comments_________________________________________________________________________________RECALLStop Recall?Recall #1CommentsRecall #2USE?____________________© 2009 Computer Programs and Systems, Inc.

76Mammography WorkbookCommentsRecall #3Comments_______________© 2009 Computer Programs and Systems, Inc.

Questionnaire and Information Tables 775.4 Mammography Data Fields ControlThe Mammography Data Fields Control table is where the data that will be captured is defined.This section explains how this table is accessed. Each facility determines the options to beutilized.1. From the Mammography Control Table Menu, select Data Fields Control.Figure 5.1 Mammo Data Fields, Page 12. The options for each field in this control table are Y (yes) check mark or N (no) no check mark.The default is N (no). Select one of the following options:· Select the desired fields to track via the Mammo System.· Select All or Deselect All to enter Y (yes) or N (no) in all fields.NOTE: If the decision is made to later add fields to the mammogram record, the system will notretrospectively add them to pre-existing mammogram records. The system will prompt for“EFFECTIVE DATE” when a field is changed from NO to YES. All complete records prior to thedate entered will remain complete.© 2009 Computer Programs and Systems, Inc.

78Mammography Workbook5.5 Mammography Patient Profile StatisticsThe Patient Profile Statistics report provides population statistics based on facility-definedparameters. See pages 4.16 - 4.18 in this workbook for a sample report. Please list the codesyour facility would like to use. If additional space is needed, please add on a separate sheet.PATIENT AGE CATEGORIESCode Description Beginning Age Ending Age Sort Seq______ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _______MENARCHE AGE CATEGORIESCode Description Beginning Age Ending Age Sort Seq______ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _______AGE AT FIRST BIRTH CATEGORIESCode Description Beginning Age Ending Age Sort Seq______ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _____________ ________________________________________ _______ _______ _______© 2009 Computer Programs and Systems, Inc.

Questionnaire and Information Tables 795.6 Mammography Pathology SummaryThe Pathology Summary report provides totals, averages and percentages for biopsiesrecommended and performed. In addition, this report includes the type, size and stage of cancerfound, type of high-risk lesion and benign findings. This information is also presented for eachradiologist.Please see the following pages for more information regarding these codes.© 2009 Computer Programs and Systems, Inc.

80Mammography WorkbookMAMMO ASSESSMENT CATEGORY CODESPlease list the codes your facility would like to use and indicate the classification of the code fromthe list below. If you wish to include mammo transcription normals to be associated with theassessment codes, please include a copy of the normal and the name of what you would like toname the normal document.N-NegativeB-Benign Finding – NegativeP-Probably Benign Finding – Short Interval Follow-up SuggestedS-Suspicious Abnormality – Biopsy Should Be ConsideredM-Highly Suggestive of Malignancy – Appropriate Action Should Be TakenX-Unresolved – Additional Patient Data not obtained0(zero)-Need additional Images, record is incomplete and unresolved.If the facility is using American College of Radiology standards for assessment codes (BI-RADS),each facility must have at least one assessment code for each of the following categories:0 – (zero): Needs additional image evaluation1 – Negative2 – Benign Finding3 – Probably Benign Finding-Short interval follow-up suggested4 – Suspicious Abnormality-Biopsy should be considered.5 – Highly Suggestive of Malignancy-Appropriate action should be taken.6 – Known Biopsy-Proven Malignancy-Appropriate action should be taken.NOTE: The BIRAD 6 code is an optional code to be used if a site deems necessary. This categoryis reserved for lesions identified on the imaging study with biopsy proof or malignancy prior todefinitive therapy. This category is appropriate for second opinions on findings previously biopsiedand shown to be malignant.Code Description Classification______ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ______© 2009 Computer Programs and Systems, Inc.

Questionnaire and Information Tables 81PATHOLOGY FINDINGS CATEGORY CODESPlease list the codes your facility would like to use and indicate the classification of the code fromthe list below.C-CancerL-High Risk LesionY-Cyst (Benign)B-Benign, other than CystN-No finding, patient did not return for recommend follow-upCode Description Classification______ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ______CANCERS BY SIZEPlease list the dimension categories you would like to use.Code Description Classification______ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ______© 2009 Computer Programs and Systems, Inc.

82Mammography WorkbookCANCERS BY STAGEPlease list the stage categories you would like to use.Code Description Classification______ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ____________ _________________________________________________ ______© 2009 Computer Programs and Systems, Inc.

Questionnaire and Information Tables 835.7 Additional Mammo InformationInstructions: The number of codes that will be defined is determined by each facility. Ifadditional space is needed, please add on a separate sheet. If you choose not to trackcertain information such as breast composition or biopsy type, the correspondinginformation will not need to be included. Please indicate the codes and descriptions youwould like to be used for the following information.1. Mammography technologists’ names and initials.NAME INITIALS (please use 3 initials) PASSWORD (Up to 6 characters)__________________________ _____________ ___________________________________ _____________ ___________________________________ _____________ ___________________________________ _____________ ___________________________________ _____________ _________2. Radiologists’ names and initials.RADIOLOGISTS NAME__________________________________________________________________________________________________________________________________INITIALS (please use 3 initials)_________________________________________________________________3. Notification codes and descriptions. (Each notification code can be up to 5 characters inlength.) Please attach a letter that will be associated with each code.Please indicate if youwould like any notification codes to automatically be associated with specific assessmentcodes.EXAMPLE: CODE DESCRIPTIONNEGNEGATIVE EXAMCODE DESCRIPTION__________________________________________________________________________________________________________________________________________________________________________________________________________________© 2009 Computer Programs and Systems, Inc.

84Mammography Workbook4. Recall codes and descriptions. (Each recall code can be up to 5 characters in length.) Pleaseattach a letter that will be associated with each code. Please indicate if you would like any recallcodes to automatically be associated with specific assessment codes.EXAMPLE:CODE1YRDESCRIPTIONONE YEAR RECALLCODE DESCRIPTION SHORT TERM F/U: Y/N______ ___________________ ___________ ___________________ ___________ ___________________ ___________ ___________________ ___________ ___________________ _____5. Biopsy type codes and descriptions. (Each biopsy type code can be up to 5 characters inlength.)EXAMPLE: CODE DESCRIPTIONSTERESTEREOTACTIC BIOPSYCODE________________________DESCRIPTION____________________________________________________________________________© 2009 Computer Programs and Systems, Inc.

Questionnaire and Information Tables 856. Mass shape codes and descriptions. (Each mass shape code can be up to 5 characters inlength.)EXAMPLE: CODE DESCRIPTIONELIPTELLIPTICAL SHAPECODE________________________DESCRIPTION____________________________________________________________________________7. Mass region codes and descriptions. (Each mass region code can be up to 5 characters inlength.)EXAMPLE: CODE DESCRIPTIONRUQRIGHT UPPER QUADRANTCODE________________________DESCRIPTION____________________________________________________________________________8. Mass margin codes and descriptions. (Each mass margin code can be up to 5 characters inlength.)EXAMPLE: CODE DESCRIPTIONPOORPOORLY DEFINEDCODE________________________DESCRIPTION____________________________________________________________________________© 2009 Computer Programs and Systems, Inc.

86Mammography Workbook9. Mass density codes and descriptions. (Each mass densities code can be up to 5 characters inlength.)EXAMPLE: CODE DESCRIPTIONHIGHHIGH DENSITYCODE________________________DESCRIPTION____________________________________________________________________________10.Mass calcification codes and descriptions. (Each mass calcification code can be up to 5characters in length.)EXAMPLE: CODE DESCRIPTIONCLUSTCLUSTEREDCODE________________________DESCRIPTION____________________________________________________________________________11.Breast surgery type codes and descriptions. (Each breast surgery type code can be up to 5characters in length.)EXAMPLE: CODE DESCRIPTIONMASTMASTECTOMYCODE________________________DESCRIPTION____________________________________________________________________________© 2009 Computer Programs and Systems, Inc.

Questionnaire and Information Tables 8712.Breast composition codes and descriptions. (Each breast composition code can be up to 5characters in length.)EXAMPLE: CODE DESCRIPTIONDENDENSECODE________________________DESCRIPTION____________________________________________________________________________13.Mammogram type codes, descriptions and classifications. (Each mammogram type code canbe up to 5 characters in length.)EXAMPLE: CODE DESCRIPTION CLASSIFICATIONFM FIRST MAMMOGRAM A-FIRST MAMMOGRAMClassificationsCODE DESCRIPTION CLASSIFICATION______ ___________________ _________________________ ___________________ _________________________ ___________________ _________________________ ___________________ ___________________A – First MammogramB – Regular Interval ReturnC – Scheduled Short-term Interval ReturnD – Early Return (Due to Symptoms)E – Late Return© 2009 Computer Programs and Systems, Inc.