59MDWI44-177 — Mammography Clinic Patient Questionnaire

59MDWI44-177 governs the completion and submission of 59 MDW Form 4001, the Mammography Clinic Patient Questionnaire.

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• Publication number: 59MDWI44-177
• Title: MAMMOGRAPHY CLINIC PATIENT QUESTIONNAIRE
• Date: 2021-08-02

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It covers documenting patients’ past and present medical history and pertinent medical and breast health information for mammographic examinations. It requires the form to be maintained in the patient’s Mammography folder or scanned into PACS, with specified destruction and recordkeeping provisions.

Applies to: This instruction applies to all personnel assigned, attached or under contract to the 59th Medical Wing.

Topics covered

• Mammography patient questionnaire
• Medical history
• Breast health information
• Mammographic examination
• Mammography folder
• Picture Archival Communication System
• Forms submission

Questions and answers

What is 59 MDW Form 4001 used to document?

Patients, mammography technologists, and providers use 59 MDW Form 4001 to document pertinent medical and breast health information to use during the Mammographic examination. (paragraph 2)

Where must 59 MDW Form 4001 be maintained?

59 MDW Form 4001 will be maintained in the patient’s Mammography folder and/or scanned into the Picture Archival Communication System (PACS). (paragraph 3)

What happens to Form 4001 if it is scanned into PACS?

If scanned into PACS, 59 MDW Form 4001 will be destroyed. (paragraph 3)

Is the mammography form scanned into Armed Forces Health Longitudinal Technology Application?

The form is not scanned into Armed Forces Health Longitudinal Technology Application. (paragraph 3)

What information does the Mammography patient questionnaire document?

The purpose of 59 MDW Form 4001 is to document the past and present medical history of our Mammography patients. (paragraph 1)

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