STANDARD DATA DICTIONARY #78.3 -- DIAGNOSTIC CODES FILE 3/24/25 PAGE 1
STORED IN ^RA(78.3, (84 ENTRIES) SITE: WWW.BMIRWIN.COM UCI: VISTA,VISTA (VERSION 5.0)
DATA NAME GLOBAL DATA
ELEMENT TITLE LOCATION TYPE
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This file contains the diagnostic codes that can be associated with an exam. The code is attached to an exam at the same time the
interpreting resident and/or staff physician is entered for the exam. The diagnostic code represents a quick overall summary of
what the interpreting physician wrote in his/her report concerning the exam. [NOTE: Diagnostic code is not the impression. The
impression is stored in the 'IMPRESSION' field of the 'RAD/NUC MED REPORTS' file (#74).]
The following is the list of codes that are loaded when the module is initialized:
1) NORMAL
2) MINOR ABNORMALITY
3) MINOR ABNORMALITY, NO ATTN, NEEDED
4) ABNORMALITY, ATTN. NEEDED
5) MAJOR ABNORMALITY, PHYSICIAN AWARE
6) UNDICTATED FILMS NOT RETURNED, 3 DAYS
7) UNSATISFACTORY/INCOMPLETE EXAM
8) POSSIBLE MALIGNANCY, FOLLOW-UP NEEDED
As part of the system customization process, these entries can be deleted. However, once the system is in production, you should
'not' delete any entries. Adding new entries is always allowed.
If the site decides to enter diagnostic codes for exams, then database searches can be performed using the 'DIAGNOSTIC CODE' field
of the exam record in the search criteria. For example, the database can be searched for all 'normal' chest procedures.
Data Storage
------------
The data for the 'DIAGNOSTIC CODES' file is stored in the ^RA(78.3, global. At the present time this file is very static after
day-one initialization is complete. However, it still should be journaled. It should also be translated if the operating system
supports this function.
Input Templates
---------------
The package does not use any input templates associated with this file.
Print Templates
---------------
The following is a list of print templates used by the package:
Name Description; Option(s)
---- ----------------------
DIAGNOSTIC CODE PRINT Prints a list of entries in this file;
RA DIAGP
Sort Templates
--------------
The package does not use any sort templates associated with this file.
APPLICATION GROUP(S): RA
IDENTIFIED BY:
"WRITE": D EN^DDIOL($$EN1^RABIRAD,"","?33")
POINTED TO BY: PRIMARY DIAGNOSTIC CODE field (#13) of the EXAMINATIONS sub-field (#70.03) of the REGISTERED EXAMS sub-field
(#70.02) of the RAD/NUC MED PATIENT File (#70)
SECONDARY DIAGNOSTIC CODE field (#.01) of the SECONDARY DIAGNOSTIC CODE sub-field (#70.14) of the EXAMINATIONS
sub-field (#70.03) of the REGISTERED EXAMS sub-field (#70.02) of the RAD/NUC MED PATIENT File (#70)
BEFORE DELETION PRIM. DX CODE field (#5) of the ACTIVITY LOG sub-field (#74.01) of the RAD/NUC MED REPORTS File
(#74)
BEFORE DELETION SEC. DX CODE field (#.01) of the BEFORE DELETION SEC. DX CODE sub-field (#74.16) of the ACTIVITY LOG
sub-field (#74.01) of the RAD/NUC MED REPORTS File (#74)
DEFAULT DX FOR 'R' REPORT field (#2.1) of the RAD/NUC MED HL7 APPLICATION EXCEPTION File (#79.7)
DEFAULT DX FOR 'F' REPORT field (#2.2) of the RAD/NUC MED HL7 APPLICATION EXCEPTION File (#79.7)
DIAGNOSTIC CODE field (#14) of the RADIOLOGY EXTRACT File (#727.814)
RADIOLOGY DIAGNOSTIC CODE field (#.02) of the WV DIAGNOSTIC CODE TRANSLATION File (#790.32)
RAD PRIMARY DIAGNOSTIC CODE field (#302) of the IMAGING SITE PARAMETERS File (#2006.1)
IMPORTER RAD DX CODE field (#124) of the DICOM GATEWAY PARAMETER File (#2006.563)
CROSS
REFERENCED BY: DIAGNOSTIC CODE(B)
LAST MODIFIED: FEB 16,2024@14:20:06
78.3,.001 NUMBER NUMBER
NUMBER OF THIS DIAGNOSTIC CODE
INPUT TRANSFORM: K:+X'=X!(X>998)!(X<1)!(X?.E1"."1N.N) X
LAST EDITED: MAR 17, 2009
HELP-PROMPT: Type a Number between 1 and 998, 0 Decimal Digits
DESCRIPTION: This field contains the number of this diagnostic code. This provides a way to do quick look-ups
of a diagnostic code by its number.
Diagnostic code numbers are assigned by the system and are between 1 and 998. Diagnostic codes
above 998 are assigned by Radiology patches.
Code Number Usage
----------- -------------------------
999-1003 Nat'l Teleradiology Prog.
1100-1106 BI-RADS
1200-1202 Abdominal Aortic Aneurysm
TECHNICAL DESCR:
The maximum limit for this field is set to 998 by patch RA*5.0*97.
SOURCE OF DATA: SYSTEM GENERATED
78.3,.01 DIAGNOSTIC CODE 0;1 FREE TEXT (Required)
NAME OF THE DIAGNOSTIC CODE
INPUT TRANSFORM: K:$L(X)>60!($L(X)<3)!'(X'?1P.E)!(X'?.ANP) X
LAST EDITED: MAR 17, 2009
HELP-PROMPT: Enter a short diagnostic code, between 3 and 60 characters in length, to indicate the results of
the image analysis.
DESCRIPTION: This field contains a short diagnostic code to indicate the results of the interpreting physician's
analysis of the images. Diagnostic codes can be between 3 and 60 characters in length and can be
used as a basis for database searches. (ie. How many 'Normal' chest exams were performed during a
specific time period?)
Eight diagnostic codes are included with the original package. Other site-specific diagnostic
codes may be entered by the rad/nuc med coordinator at each site.
TECHNICAL DESCR: This field is made uneditable by patch RA*5*97.
Patch RA*5.0*97 adds BI-RADS codes to IEN 1100 thru 1106, and AAA codes to IEN 1200 thru 1202.
Routine RABIRAD builds a string of BI-RADS IENs based upon the exact spelling of the first two
words in this field, eg. "BI-RADS CATEGORY".
DELETE TEST: 1,0)= I 1 D EN^DDIOL("Diagnostic Codes cannot be deleted. Inactivate to remove.",,"!,$C(7)")
SOURCE OF DATA: RAD/NUC MED COORDINATOR
UNEDITABLE
CROSS-REFERENCE: 78.3^B
1)= S ^RA(78.3,"B",$E(X,1,30),DA)=""
2)= K ^RA(78.3,"B",$E(X,1,30),DA)
Regular 'B' cross reference assigned by FileMan.
78.3,2 DESCRIPTION 0;2 FREE TEXT
DESCRIPTION OF THE DIAGNOSTIC CODE
INPUT TRANSFORM: K:$L(X)>80!($L(X)<1) X
LAST EDITED: AUG 29, 1984
HELP-PROMPT: Enter a description of the diagnostic code between 1 and 80 characters in length.
DESCRIPTION: This field is used to give a description of the diagnostic code and may be from 1-80 characters in
length.
SOURCE OF DATA: RAD/NUC MED COORDINATOR
78.3,3 PRINT ON ABNORMAL REPORT 0;3 SET
SHOULD THIS DIAGNOSTIC CODE SHOW UP ON ABNORMAL EXAM REPORT?
'Y' FOR YES;
'N' FOR NO;
LAST EDITED: NOV 15, 1994
HELP-PROMPT: Enter 'Y' for YES if this code should print on the Abnormal Exam Report.
DESCRIPTION: This field contains a 'Yes' or 'No' value to indicate if exams with this diagnostic code should be
printed on the 'Abnormal Exam Report'. The report is used to ensure that the physician is notified
of abnormal results of an exam. This field must be set to 'Yes' before the diagnostic code is
entered on the exam in order for that exam to appear on the 'Abnormal Exam Report'.
SOURCE OF DATA: RAD/NUC MED COORDINATOR
78.3,4 GENERATE ABNORMAL ALERT? 0;4 SET
'y' FOR YES;
'n' FOR NO;
LAST EDITED: JUL 25, 1991
HELP-PROMPT: Answering 'YES' indicates that whenever this diagnostic code is entered for a report an abnormal
alert should be sent to the attending/requesting physician.
DESCRIPTION:
If this code should generate an abnormal alert, enter 'y', yes at this prompt.
78.3,5 INACTIVE 0;5 SET
'Y' FOR YES;
LAST EDITED: DEC 23, 1996
HELP-PROMPT: Enter Y to inactive this diagnostic code, or delete the Y to re-activate this code.
78.3,6 *EXPRESSION 0;6 POINTER TO EXPRESSIONS FILE (#757.01)
LAST EDITED: SEP 08, 2023
HELP-PROMPT: This field has been deprecated and should no longer be used.
DESCRIPTION: This field has been deprecated.
This field is associated with the .01 field used for BI-RADS codes under the MQSA coding system
mandated by the FDA. Whenever the BI-RADS codes from field .01 is displayed, this field will be
used to retrieve the current FDA-mandated wording for .01 field values of "BI-RADS CATEGORY 0"
through "BI-RADS CATEGORY 6", which are in record numbers 1100 through 1106. The retrieved value
will be displayed next to the .01 field value. This field is initially populated by patch
RA*5.0*97. The Radiology application does not prompt the user for this field. Changes to data in
this field will be made by future Radiology patches.
TECHNICAL DESCR: This field is being decommissioned by patch RA*5.0*206. It will replaced by a new DISPLAY TEXT
field. This field will be deleted after 18 months.
This field was added and made uneditable by patch RA*5.0*97.
UNEDITABLE
78.3,100 DISPLAY TEXT 1;E1,245 FREE TEXT
INPUT TRANSFORM: K:$L(X)>245!($L(X)<1) X
MAXIMUM LENGTH: 245
LAST EDITED: SEP 08, 2023
HELP-PROMPT: Enter the display text of the diagnostic code between 1 and 245 characters in length. Data for this
field must be entered by a Radiology patch.
DESCRIPTION: This field is associated with the BI-RADS codes under the MQSA coding system mandated by the FDA.
Whenever the BI-RADS codes from field .01 is displayed, this field will be used to display the
current FDA-mandated wording for .01 field values of "BI-RADS CATEGORY 0" through "BI-RADS CATEGORY
6", which are in record numbers 1100 through 1106 and 1110. The retrieved value will be displayed
next to the .01 field value. This field is initially populated by patch RA*5.0*206. The Radiology
application does not prompt the user for this field. Changes to data in this field will be made by
future Radiology patches.
TECHNICAL DESCR: This field is replacing the EXPRESSION field (#6), which has been marked for deletion.
This field was added and made uneditable by patch RA*5.0*206.
UNEDITABLE
FILES POINTED TO FIELDS
EXPRESSIONS (#757.01) *EXPRESSION (#6)
INPUT TEMPLATE(S):
PRINT TEMPLATE(S):
RA DIAGNOSTIC CODE PRINT DEC 23, 1996@13:26 USER #0 DIAGNOSTIC CODES LIST
Used for printing the Diagnostic Code List.
SORT TEMPLATE(S):
FORM(S)/BLOCK(S):