Current through Register Vol. 48, No. 9, September 27, 2024
5.11.1 Contents
and terminology. Each facility shall prepare a written report of the results of
each mammography examination performed under its certificate. The mammography
report shall include the following information:
5.11.1.1 The name of the patient and an
additional patient identifier;
5.11.1.2 Date of examination;
5.11.1.3 The name of the interpreting
physician who interpreted the mammogram;
5.11.1.4 Overall final assessment of
findings, classified in one of the following categories:
5.11.1.4.1 "Negative." Nothing to comment
upon (if the interpreting physician is aware of clinical findings or symptoms,
despite the negative assessment, these shall be explained);
5.11.1.4.2 "Benign." Also a negative
assessment;
5.11.1.4.3 "Probably
Benign." Finding(s) has a high probability of being benign;
5.11.1.4.4 "Suspicious." Finding(s) without
all the characteristic morphology of breast cancer but indicating a definite
probability of being malignant;
5.11.1.4.5 "Highly suggestive of malignancy."
Finding(s) has a high probability of being malignant;
5.11.1.5 In cases where no final assessment
category can be assigned due to incomplete work-up, "Incomplete: Need
additional imaging evaluation" shall be assigned as an assessment and reasons
why no assessment can be made shall be stated by the interpreting physician;
and
5.11.1.6 Recommendations made
to the health care provider about what additional actions, if any, should be
taken. All clinical questions raised by the referring health care provider
shall be addressed in the report to the extent possible, even if the assessment
is negative or benign.
5.11.2 Communication of mammography results
to the patient. Each facility shall send each patient a summary of the
mammography report written in lay terms within thirty (30) calendar days of the
mammographic examination. If assessments are "Suspicious" or "Highly suggestive
of malignancy," the facility shall make reasonable attempts to ensure that the
results are communicated to the patient as soon as possible.
5.11.2.1 Patients who do not name a health
care provider to receive the mammography report shall be sent the report
described in
RHB 5.11.1 within thirty (30)
calendar days, in addition to the written notification of results in lay
terms.
5.11.2.2 Each facility that
accepts patients who do not have a health care provider shall maintain a system
for referring such patients to a health care provider when clinically
indicated.
5.11.3
Communication of mammography results to health care providers. When the patient
has a referring health care provider or the patient has named a health care
provider, the facility shall:
5.11.3.1 Provide
a written report of the mammography examination, including the items listed in
subsection
5.11.1 of this Section, to that
health care provider as soon as possible, but no later than thirty (30)
calendar days after the date of the mammography examinations; and
5.11.3.2 If the assessment is "Suspicious" or
"Highly suggestive of malignancy," make reasonable attempts to communicate with
the health care provider as soon as possible, or if the health care provider is
unavailable, to a responsible designee of the health care provider.
5.11.4 Record-keeping. Each
facility that performs mammograms:
5.11.4.1
Shall, except as provided in
RHB 5.11.4.2, maintain
mammography films and reports in a permanent medical record of the patient for
a period of not less than five (5) years, or not less than ten (10) years if no
additional mammograms of the patient are performed at the facility;
5.11.4.2 Shall upon request by, or on behalf
of, the patient permanently or temporarily transfer the original mammograms and
copies of the patient's reports to a medical institution, or to a physician or
health care provider of the patient, or to the patient directly; and
5.11.4.3 Any fee charged to the patient for
providing the services in
RHB 5.11.4 shall not exceed
the documented costs associated with this service.
5.11.5 Mammographic image identification.
Each mammographic image shall have the following information indicated on it in
a permanent, legible, and unambiguous manner and placed so as not to obscure
anatomic structures:
5.11.5.1 Name of patient
and an additional patient identifier.
5.11.5.2 Date of examination.
5.11.5.3 View and laterality. This
information shall be placed on the image in a position near the axilla.
Standardized codes specified by the accreditation body shall be used to
identify view and laterality.
5.11.5.4 Facility name and location. At a
minimum, the location shall include the city, state, and zip code of the
facility.
5.11.5.5 Technologist
identification.
5.11.5.6
Cassette/screen identification.
5.11.5.7 Mammography unit identification, if
there is more than one (1) unit in the facility.
