Form Cms-1882 - Portable Xray Survey Report Page 6
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10name of facility
not
standards
code
met
n/a
eXplanatory statement
met
h37
§486.106 referral for service and preservation of
records
all portable X-ray services performed for medicare
beneficiaries are ordered by a doctor of medicine or doctor of
osteopathy and records are properly preserved.
H38
(a) referral by a physician
Portable X-ray examinations are performed only on the order
of a doctor of medicine or doctor of osteopathy licensed to
practice in the state. the supplier’s records show that:
(1) the X-ray test was ordered by a licensed doctor of
medicine or doctor of osteopathy, and
(2) Such physician’s written, signed order specifies the reason
an X-ray test is required, the area of the body to be
exposed, the number of radiographs to be obtained, and
the views needed; it also includes a statement concerning
the condition of the patient which indicates why portable
X-ray services are necessary.
H39
(b) records of examinations performed
the supplier makes for each patient a record of the date of the
X-ray examination, the name of the patient, a description of the
procedures ordered and performed, the referring physician, the
operator(s) of the portable X-ray equipment who performed the
examination, the physician to whom the radiograph was sent,
and the date it was sent.
H40
(c) preservation of records
such reports are maintained for a period of at least 2 years, or
for the period of time required by state law for such records
(as distinguished from requirements as to the radiograph
itself), whichever is longer.
number of physicians’ orders reviewed
H41
Physicians’ justification for portable X-rays recorded.
1.
yes
2.
no
6
form cms-1882 (02/09)
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