CMS SOM App. A, Tag A-1051

The hospital must maintain signed and dated reports of nuclear medicine

interpretations, consultations, and procedures.

(1) The hospital must maintain copies of nuclear medicine reports for at least 5

years.

(2) The practitioner approved by the medical staff to interpret diagnostic

procedures must sign and date the interpretation of these tests.

Interpretive Guidelines §482.53(d)(1) & (2)

Nuclear medicine patient records, including interpretations, consultations, and procedures

are patient medical records and the hospital must comply with the Medical Records CoP

(§482.24).

Nuclear medicine patient records, like all patient medical records, must be maintained 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. Each report of an interpretation of a nuclear medicine diagnostic study must be

signed and dated by the practitioner who made the interpretation, as authorized by the

medical staff. Deficient nuclear medicine medical records practices related to these two

requirements must be cited under this regulation; depending on the specific facts, citation

under the Medical Records CoP might also be appropriate.

Survey Procedures §482.53(d)(1) & (2)

• Verify that copies of nuclear medicine reports are maintained for at least 5 years.

• Verify that reports of nuclear medicine interpretations are signed and dated only by

the practitioner who interpreted the study’s results, as authorized by the medical staff

to perform these interpretations