Current through Bulletin 2024-06, March 15, 2024
(1) A medical
record shall be maintained for each patient on whom screening or diagnostic
mammography is performed.
(a) Provision shall
be made for the filing, safe storage and accessibility of medical
records.
(b) Records shall be
protected against loss, defacement, tampering, fires, and floods.
(c) Records shall be protected against access
by unauthorized individuals.
(d)
All records shall be readily available upon the request of:
(i) The attending physician,
(ii) Authorized representatives of the
Department for determining compliance with licensure rules;
(iii) Any other person authorized by written
consent.
(e) The
facility shall establish a system to assure that the patient's mammogram is
accessible for clinical follow-up when requested.
(i) A copy of the mammogram and other
appropriate information shall be sent to the requesting party responsible for
subsequent medical care of the patient no later than 14 working days from the
request for information. This shall include the full notification and follow up
required under Utah Code
26-21a-206
and Administrative Code
R432-950-14.
(ii) Medical information may be released only
upon the written consent of the patient of her legal representative.
(2) The facility shall
attempt to obtain a prior mammogram for each patient if the prior mammogram is
necessary for the physician to properly interpret the current exam.
(3) The interpreting physician shall prepare
and sign a written report of his interpretation of the results of the screening
mammogram.
(a) The written report shall
include a description of detected abnormalities and recommendations for
subsequent follow-up studies.
(b)
The interpreting physician shall render the report as soon as reasonably
possible.
(c) The interpreting
physician or his designee shall document and communicate the results of the
report to the referring physician or his designated representative by
telephone, by certified mail, or in such a manner that receipt of the report is
assured.
(d) The interpreting
physician or his designee shall notify self-referred patients, that is,
patients who have no referring physician, of the results of the screening study
in writing and in lay language.
(4) The interpreting physician or his
designee shall document and communicate the results of all diagnostic reports
in the high probability category with suspicion of breast cancer to the
referring physician or his designated representative by telephone, by certified
mail, or in such a manner that receipt of the report is assured.
(5) The physician shall document and
communicate in person in lay language, by certified mail, or in such a manner
that receipt of the diagnostic report is assured to all self-referred patients
within the high probability category with a suspicion of breast cancer. The
report shall indicate whether the patient needs to consult with a physician.
(a) The interpreting physician or his
designee shall attempt to make a follow-up contact with the patient to
determine whether she has consulted a physician for follow-up care.
(b) The interpreting physician or his
designee shall document in the patient's medical record attempts to communicate
the results to the patient.
(6) The facility shall retain the original
and subsequent mammograms for a period of at least five years from the date of
the procedure.
