Ill. Admin. Code tit. 32, § 370.130 - 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.
a) General requirements. Each facility shall
establish a system to collect and review outcome data for all mammograms
performed, including followup 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 followup on
surgical and/or pathology results and review of the mammograms taken prior to
the diagnosis of a malignancy.
b)
Frequency of audit analysis. The facility's first audit analysis shall be
initiated no later than 12 months after the date the facility becomes
certified. This audit analysis shall be completed within an additional 12
months to permit completion of diagnostic procedures and data collection.
Subsequent audit analyses will be conducted at least once every 12
months.
c) Audit interpreting
physician. Each facility shall designate at least one interpreting physician to
review the medical outcomes audit data at least once every 12 months. This
individual shall record the dates of the audit periods 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 followup
actions are taken, the audit interpreting physician shall also be responsible
for documenting the nature of the followup.
Notes
Amended at 29 Ill. Reg. 20963, effective December 16, 2005
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