R432-950-13. Mammography Records

  (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.