Mammography Workbook - CPSI Application Documentation

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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.
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