CMS SOM App. A, Tag A-0553

Records of radiologic services must be maintained.

(1) - The radiologist or other practitioner who performs radiology services must sign

reports of his or her interpretations.

(2) - The hospital must maintain the following for at least 5 years:

(i) Copies of reports and printouts.

(ii) Films, scans, and other image records, as appropriate.

Interpretive Guidelines §482.26(d)

The hospital must maintain records for all radiologic procedures performed. At a minimum, the

records must include the orders for the services, copies of reports and printouts, and any films,

scans, digital or other image records, as appropriate.

Radiology films, image records, scans, digital files, reports, and printouts must be secure and

properly stored for at least five years. If State law requires a longer period, the hospital must

comply, but surveyors do not assess compliance with State law requirements as part of the

Federal survey. Patient radiologic services records are considered patient medical records and

the hospital must comply with the requirements of the medical records CoP (§482.24). All

reports of studies must be signed by the radiologist or other authorized practitioner (in the case of

studies not designated as requiring a radiologist to interpret them) who reads and evaluates the

findings of the study. Acceptable forms of signature include paper signatures as well as

electronic signatures.

Survey Procedures §482.26(d)

• Determine whether the hospital maintains radiologic services records for at least 5 years after

the study or procedure. (Assess them for compliance with the Medical Records CoP at

§482.24 at the same time, but make sure to cite general medical record noncompliance under

that CoP.)

• Request records for all different imaging modalities furnished by the hospital, to determine if

the procedure for maintaining the records is consistent among all the radiologic services.

• Review radiologic records to determine that reports of studies are signed by the radiologist or

other authorized practitioner (in the case of studies not designated as requiring a radiologist

to interpret them ) who read and evaluated the findings of the study