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The physician reviewing the chest x-ray and documenting the patient's final diagnosis in the discharge summary as aspiration pneumonia reflects which crieteria for high quality clinical documentation?

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bharathparasad577

An infection of the air sacs in one or both lungs is known as pneumonia. characterized by a dry, phlegmy cough, a high fever, chills, and breathing difficulties.

1. Record the time and date the CXR was done because it can be very different from the time you are recording.

2. Type the CXR's indication (such as "productive cough, shortness of breath, and fever - probable community-acquired pneumonia") in the space provided.

3. Explain how you interpreted the CXR:

  • image excellence
  • Rotation \sInspiration
  • Projection
  • Airway: Bronchi and the trachea
  • funny structures
  • Lung fields: lungs
  • Cardiac Pleura: Heart size
  • heart's edges
  • Diaphragm:
  • Position/shape
  • angle costsophrenic
  • Other than that
  • internal contours
  • Bones
  • Tubes/valves/devices

4. Describe how you feel about the CXR overall (for instance, "left lower lobe consolidation").

5. Using the results of the CXR, document your plan.

Learn more about Pneumonia here:
https://brainly.com/question/27242583

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