Wiki Dx ? for CXR

[Kimberley]

I work for an imaging center and have numerous x-ray reports that come across stating the following....what dx should I be using? Help!!

INDICATION: PNEUMONIA

IMPRESSION: No active disease of the chest.

FINDINGS: Tubes and lines. None.

Lungs: Clear bilaterally without focal consolidation, pleural effusion or edema.

Cardiomediastinal silhouette: Within normal limits.

regional osseous structures/soft tissues: Mild degenerative changes of the spine.

 

[mitchellde]

AB-01-144 States that you may use the physician's dx as the indication for the test as the dx, so looks like pneumonia.