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Radiology findings

This sample was reviewed and approved by the ACDIS Resource Library Committee in 2023. The committee noted that if you use this resource, it requires a space to index clinical indicators, and  the resource must be rid of all bold and underlined phrases, as these are considered leading queries and non-compliant. This query form is a request for documentation clarification or confirmation of radiology findings. It was submitted by Paul Evans, RHIA, CCS, CCS-P, supervisor of clinical documentation integrity at Sutter Health in San Francisco

 

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