D.6 SOP - Mammogram Tracking Guidelines GVSMVAMC.docx
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About this file
This document outlines standard operating procedures for tracking mammograms at the G.V. (Sonny) Montgomery VA Medical Center in Jackson, Mississippi. Responsibilities are assigned to the Women's Health Coordinators and Program Support Assistant to receive mammogram reports, enter information into a tracking spreadsheet, and ensure results are scanned into the VA's medical record system with appropriate follow-up actions by radiology, nursing, and medical staff within five business days. The procedures are established to comply with VA directives on healthcare services for women veterans and will be reviewed every three years by the medical center's Chief of Quality Management.
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Mammogram Tracking Standard Operating Procedure
SOP
Link to Resources for Implementation of VHA Policy SharePoint site: https://dvagov.sharepoint.com/sites/VACOVHACOS/10B4/PIRP/10B4/SitePages/Home.aspx Link to Resources for Implementation of VHA Policy SharePoint site: https://dvagov.sharepoint.com/sites/VACOVHACOS/10B4/PIRP/10B4/SitePages/Home.aspx G.V. (Sonny) Montgomery VAMC Jackson, Mississippi 39216 Signatory Authority:
GVSMVAMC Chief of Staff GVSMVAMC Deputy Associate Chief of Staff Primary Care Responsible Owner:
GVSMVAMC Chief of Quality Management Service Line(s):
Primary Care Effective Date:
March 30, 2021 Recertification Date:
March 30, 2024
1. PURPOSE AND AUTHORITY
a. This standard operating procedure (SOP) sets forth to establish and provide guidance to staff for tracking mammograms in Women’s health and ensure compliance to VHA Directive 1330.01 (4) Health Care services to women Veterans, dated February 15, 2017;amended January 8, 2021.
b. The purpose of this SOP is to establish procedures and responsibility for tracking mammograms. This SOP must be followed by all G.V. (Sonny) Montgomery VA Medical Center (GVSMVAMC) and Community based Outpatient Clinics (CBOC) designated personnel. The Women’s Health Coordinators (WHC) along with the Women Veterans Program (WVPM) and/or Women’s Health Medical Director (WHMD) is responsible for developing, implementing the tracking procedures for compliance of the mammograms. It is the responsibility of the WHCs to track mammograms. The Program Support Assistant (PSA) will assist as designee when one of the coordinators are on leave.
2. PROCEDURES
a. The Women Health Coordinators/Program Support Assistant and CBOCs designees (liaisons) will track mammograms upon receipt.
b. The GVSMVAMC Women Health Coordinators/Program Support Assistant and CBOC designees (liaisons) will utilize the attached guidelines to track and ensure appropriate follow up of mammograms for completion (see attachment).
c. In the event of one of the Women Health Coordinators absences, the second coordinator along with the PSA will track and ensure appropriate follow up has been completed.
d. Included in the tracking process, the WHC will case, register and validate/verify the report in VISTA as appropriate.
e. The GVSMVAMC radiology designees will continue to play a limited supporting role to assist with problems or questions which may arise concerning the radiology package.
3. ASSIGNMENT OF RESPONSIBILITIES
a. GVSMVAMC Chief of Quality Management. In accordance with the responsibility in VHA Directive 1330.01 (4) Health Care Services for Women Veterans, Chief of Quality Management/team for the GVSMVAMC, in collaboration with the WVPM, Radiology Service and Primary Care Service will oversee the tracking and timeliness of follow-up of findings from breast screenings of mammograms in accordance with procedures in this SOP.
b. GVSMVAMC Associate Chief of Primary Care. The GVSMVAMC Associate Chief of primary Care in collaboration with the Quality Management Chief/team in collaboration with the WVPM, Radiology Service and Primary Care Service will oversee the tracking and timeliness of follow-up of findings from breast screenings of mammograms in accordance with procedures in this SOP is responsible for in accordance with procedures in this SOP and requirements in VHA Directive 1330.01 (4) Healthcare Services for Women Veterans.
4. DEFINITIONS
None.
5. REFERENCES
VHA Directive 1330.01 (4) Health Care Services for Women Veterans, dated February 15, 2017/amended January 8, 2021.
6. REVIEW
This SOP must be reviewed at minimum at recertification and including when there are changes to the governing document, VHA Directive 130.01. This review is documented on the GVSMVAMC Facility SharePoint site Medical Center Policies and Memoranda see:https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx (see). NOTE: This is an internal VA Web site that is not available to the public.
7. RECERTIFICATION
This SOP is scheduled for recertification on or before the last working day of February 2024. In the event of contradiction with national policy, the national policy supersedes and controls.
8. SIGNATORY AUTHORITY
Rachel Peery, MD,FACP GVSMVAMC Chief of Staff Date Approved: March 30, 2022 Andree’ A. Burnett, MD GVSMVAMC Deputy Associate Chief of Staff Primary Care Date Approved: March 30, 2022 NOTE: The signature remains valid until rescinded by an appropriate administrative action.
DISTRIBUTION: Emailed to the GVSMVAMC Quality Management Employees Email Distribution List, Primary Care Employees Email Distribution List, Radiology Employee Email Distribution List and the GVSMVAMC Chief of Staff Women health Employees Email Distribution List on March 30, 2022. SOPs are available at: GVSMVAMC Facility SharePoint site Medical Center Policies and Memoranda https://dvagov.sharepoint.com/sites/vhajac/policiesmemos/Forms/sortbyname.aspx?viewpath=%2Fsites%2Fvhajac%2Fpoliciesmemos%2FForms%2Fsortbyname.aspx http://vaww.va.gov/Anytown_Publications/. NOTE: This is an internal VA Web site that is not available to the public.
Mammogram tracking Guidelines
| 1. | Receive mammogram reports from various Non-VA Care Consults vendors. |
| 2. | Once received, enter information onto the mammography data tracking spread sheet which is located on the Women’s drive Mammography folder). All outsourced mammogram results (BI-RADS codes) are entered in the radiology package of Veterans Health Information Systems and Technology Architecture (VistA) and associated to a radiology order in Computerized Patient Record System (CPRS). |
| 3. | Upon the end of each day, email a copy of the report with a coversheet. This information is also located on the women’s drive in the mammography folder (Vista Capture Form Filled Shortcut). After completion of this form, attach it to the report. |
| 4. | Email should be sent to Sam Hollis (Radiology)Talvea Seawood, (Radiology), Robin Shaw (UR Nurse), Susan Scott (UR Nurse), Debra Pierce-Robinson (WVPM), Brittany Brooks, Md WHMD), Coretta Hurd (RN-WH Clinic), Deborah Milliken, (NP-WHC), Latanya Sessoms (RN-WH Clinic), Mudeshea Monroe( RN-WHC), Eddis Baker (RN- WHC) & Tina Moore (WH-PSA). |
| 5. | Allow 5 business days from date mammograms were emailed; verify reports are: (1) scanned into VISTA imaging, (2) confirm mammography consult is closed with (report attached), and (3) confirm mammogram has been correctly entered. |
| 6. | To confirm case/registered: (A) Click reports (B) Click Imaging (C) Search for mammography |
| Product Name |
| Department |
| Contact Number(s) |
Sam Hollis Talvea Seawood
| Radiology |
| 55089 |
55410 51333
Robyn Shaw Susan Scott
| Utilization Nurse, Office of Community Care |
| 22812 |
22700
Mudeshea Monroe Eddis Baker
| RN-WHC(s) |
| 51376 |
55655
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