What medical records will the MQSA inspector ask to see?
The inspector will ask to see records of mammography reports. The inspector will also randomly select records to assure that reports contain identification of the interpreting physician and final assessment categories of results and that films are present. The facility should also be prepared to show the inspector randomly selected samples of reports it has provided to referring health care providers and to self-referred patients, if the facility accepts self-referrals.
For hard-copy records, the inspector may ask to see a list of patients who have had mammograms, randomly pick out 5 names, and ask the technologist to pull the cases. To review electronic records, the inspector may ask the facility personnel to bring up the “Records” file(s) on the computer. He/she will then select 5 medical reports at random and review the reports for the required information.