S.C. Code Regs. § § 61-64.V.RHB 5.23

Current through Register Vol. 48, No. 10, October 25, 2024

Section 61-64.V.RHB 5.23 - Mammography Medical Outcomes Audit

Each facility shall establish and maintain a mammography medical outcomes audit program to follow-up positive mammographic assessments and to correlate pathology results with the interpreting physician's findings. This program shall be designed to ensure the reliability, clarity, and accuracy of the interpretation of mammograms.

5.23.1 General Requirements. Each facility shall establish a system to collect and review outcome data for all mammograms performed, including follow-up on the disposition of all positive mammograms and correlation of pathology results with the interpreting physician's mammography report. Analysis of these outcome data shall be made individually and collectively for all interpreting physicians at the facility. In addition, any cases of breast cancer among patients imaged at the facility that subsequently become known to the facility shall prompt the facility to initiate follow-up on surgical and/or pathology results and review of the mammograms taken prior to the diagnosis of a malignancy.

5.23.2 Frequency of audit analysis. The facility's first audit analysis shall be initiated no later than twelve (12) months after the date the facility becomes certified, or twelve (12) months after April 28, 1999, whichever is later. This audit analysis shall be completed within an additional twelve (12) months to permit completion of diagnostic procedures and data collection. Subsequent audit analyses shall be conducted at least once every twelve (12) months.

5.23.3 Reviewing interpreting physician. Each facility shall designate at least one (1) interpreting physician to review the medical outcomes audit data at least once every twelve (12) months. This individual shall record the dates of the audit period(s) and shall be responsible for analyzing results based on this audit. This individual shall also be responsible for documenting the results, notifying other interpreting physicians of their results and the facility aggregate results. If follow-up actions are taken, the reviewing interpreting physician shall also be responsible for documenting the nature of the follow-up.

S.C. Code Regs. § 61-64.V.RHB 5.23

Replaced and amended by State Register Volume 40, Issue No. 06, eff. 6/24/2016; State Register Volume 47, Issue No. 05, eff. 5/26/2023.