Guidance

Breast screening: Attended not screened guidance

Published 16 May 2024

Applies to England

There are certain scenarios where a woman may attend her screening appointment, but not have any images taken:

• the woman reports that she had mammograms taken within the last 6 months
• the woman reports that she had mammograms taken, but can’t remember when and it may have been within the last 6 months
• the woman changes her mind and withdraws consent, either at reception or in the X-ray room
• the woman turns up late to her appointment and it is not possible to screen her
• clinical reasons prevent the mammogram from being taken
• where 2 assistant practitioners are working with remote radiographic supervision and are unable to take images such as where she has implanted medical devices or breast implants
• equipment failure

When a woman attends for breast screening, as well as identification checks (name, address, date of birth) the mammographer must ask a woman if she has had a mammogram since her last NHS breast screening programme mammogram or whether they have ever had a mammogram for first time attendees. Verbal confirmation is sufficient and does not require further checks. Any mammogram taken between screening appointments must be documented on the client form to include as much information as possible regarding:

• place image taken
• date taken
• symptomatic, private or other screening service
• outcome of mammogram

This information will be entered onto NBSS by the breast screening administration team as an other imaging (OTH IMG) record. Image readers will then see on the client record that other images have been taken should they want to request and review previous images when reporting current screening images. Further guidance on adding an other imaging can be found on www.nbss.nhs.uk.

1. Mammographer recording of attended not screened

The mammographer must record on NBSS if a woman has attended her appointment but has not been screened.

There are various ways in which this can be recorded in NBSS:

• via the Mammographer Direct Entry (SMDE) function
• via the NBSS Daybook, used where live access to NBSS is not available

The image below shows how a woman is marked in the NBSS Daybook and SMDE screens as having attended, but not screened. The ‘Not screened’ box must be ticked and an appropriately detailed free text comment added to the ‘Comment’ box. This comment should acknowledge that an attended not screened client information,  has been given and record the reason for the mammogram not taking place.

Local protocols will dictate whether anything is also recorded on either the clinic control sheet or client form.

Women who have attended their appointment but not been screened should be included in the end of day checks to make sure that all women have been accounted for on the clinic control sheet.

Prior to episode closure within the screening office, checks should be carried out to ensure that all attended not screened clients have been recorded correctly on NBSS and in line with local protocols.

2. Attended not screened scenarios

The following outline the most common scenarios which occur, with advice on:

• how the mammographer should handle the situation
• the information requiring recording on NBSS
• the information to be provided to the woman

These scenarios are not exhaustive and there may be additional times where mammographers need to use their professional discretion such as suspected breast implant rupture. In such circumstances it is important that the woman is clearly informed what the next steps are for her and that this is accurately recorded in NBSS with an appropriately detailed comment. The comments made on the client form and / or NBSS should make it clear to the screening administration team where action is required and what this action should be based on the advice given to the woman.

If it is not possible to fully confirm the client’s full name, date of birth and address then no images should be taken. Further guidance is available online.

The corresponding code (such as NS1) on the attended not screened client information should be included in the NBSS comments to support the screening administration team.

2.1 Women attends a screening appointment and reports she has a symptomatic appointment booked (NS1)

If a woman reports that she has a symptomatic hospital appointment booked, no images should be taken at this appointment.

The woman should be advised to attend her upcoming hospital appointment and be given a copy of the attended not screened client information, annotated appropriately by the mammographer. The mammographer must update NBSS to record that the woman attended her appointment but was not screened, with an appropriately detailed comment, citing reason code NS1. The comment should include the date of the hospital appointment as informed by the woman. 

It is advisable for the breast screening administration team to create an other imaging (OTH IMG) record on NBSS for reference at future screening appointments.

2.2 Woman reports having had a mammogram within the last 6 months (NS2)

If a woman reports that she has had a mammogram taken within the last 6 months, no images can be taken at this appointment. Further guidance is available online. This is regardless of where the images were taken, whether they were screening or symptomatic images and whether or not they were taken within the UK.

The woman should be given a copy of the attended not screened client information, annotated appropriately by the mammographer. The mammographer must update NBSS to record that the woman attended her appointment but was not screened, with an appropriately detailed comment, citing reason code NS2. The comment should include as much information as is known and will ideally include that the woman had recent images taken, date taken and the hospital or location.

2.3 Woman reports having had a recent mammogram but is not sure of the date (NS3)

If the woman indicates that she has had images taken, but is unsure of the date and it could be within the last 6 months further checks need to be made before any images can be taken at this appointment. This is regardless of where the images were taken, whether they were screening or symptomatic images and whether or not they were taken within the UK.

If there is enough time during the screening appointment, and there is a live access from the screening location to relevant IT systems, the mammographer can complete a search on hospital systems to determine the imaging date. Based on this information, the woman should be advised when she is eligible for screening and to contact the screening service to arrange another appointment. This will depend on local practices, access and where the images were taken.

If this is not possible, the woman should be given a copy of the attended not screened client information, annotated appropriately by the mammographer. The mammographer must update NBSS to record that the woman attended her appointment but was not screened, with an appropriately detailed comment, citing reason code NS3. The comment should include that the woman had recent images taken, estimated dates and the hospital or location.

When reconciling the breast screening clinic session, the breast screening administration team will check on all available hospital systems to see whether an imaging date can be confirmed. The screening administration team must contact the woman either to arrange an appointment or to ask her to request an appointment date when at least 6 months has passed since her previous mammogram.

If the date of previous imaging can not be determined, the woman should be asked to request a screening appointment 6 months from when she attended her screening appointment and was not screened.

2.4 Woman withdraws consent, either at reception or in the X-ray room (NS4)

If a woman attends, but withdraws consent without having any images taken, then she must be recorded as attended not screened.

In this situation the mammographer would ask the woman whether she would like another appointment to be arranged for a future date whilst she is still at the screening unit. Depending on local practices and whether there is live access to NBSS, this may either be completed directly by the mammographer or by telephoning the screening office.

If no further appointment is made, the woman should be given a copy of the attended not screened client information, annotated appropriately by the mammographer. The mammographer must update NBSS to record that the woman has attended her appointment but was not screened, with an appropriately detailed comment, citing reason code NS4.

If a woman withdraws consent part way through an examination and at least half of the breast can be demonstrated on one or more views of the routine examination, this should be recorded as a partial mammogram. In this situation, the woman should not be recorded on NBSS as attended not screened.

2.5 Clinical reasons (NS5)

The mammographer may not be able to carry out a mammogram due to clinical reasons such as an open wound or temporary / permanent disability that prevents mammography being completed. The woman should be given a copy of the attended not screened client information, annotated appropriately by the mammographer. The mammographer must update NBSS to record that the woman has attended but was not screened, with an appropriately detailed comment, citing reason code NS5.

If a woman attends who has had a bilateral mastectomy which was not recorded on NBSS, the mammographer must record this information on the client form and an appropriately detailed comment in the attended not screened NBSS record to denote bilateral mastectomy. This should be followed up by the screening administration team when reconciling the clinic. They will need to obtain clinical information to support the woman being ceased from the programme.

2.6 Assistant practitioners working with remote radiographic supervision (NS6)

The NHS BSP guidance for breast screening mammographers outlines certain examinations which must be undertaken by a HCPC registered radiography practitioner. This includes women with breast implants or implanted medical devices such as pacemakers. In these circumstances should a woman attend for screening without the service having prior knowledge and 2 assistant practitioners are working with remote supervision no images can be taken at this appointment.

In this situation the woman should be advised that a specialist clinic is required for her appointment. Ideally, the mammographer would arrange a new appointment for the woman whilst she is still at the screening unit. Depending on local practices and whether there is live access to NBSS, this may either be completed directly by the mammographer or by telephoning the screening office.

Where it has not been possible to arrange another appointment, the woman should be given a copy of the attended not screened client information, annotated appropriately by the mammographer and be advised to contact the screening office to book another appointment. The mammographer must update NBSS to record that the woman has attended her appointment but was not screened, with an appropriately detailed comment, citing reason code NS6.

2.7 Late or wrong day attendance (NS7)

If a woman is late for her appointment, or attends an appointment on the wrong day, every effort should be made to screen her on that day. However, in exceptional circumstances, it may not be possible for the mammographer to carry out her screen.

Ideally, in this situation the mammographer would arrange a new appointment for the woman whilst she is still at the screening unit. Depending on local practices and whether there is live access to NBSS, this may either be completed directly by the mammographer or by telephoning the screening office.

Where it has not been possible to arrange another appointment, the woman should be given a copy of the attended not screened client information, annotated appropriately by the mammographer and be advised to contact the screening office to book another appointment. The mammographer must update NBSS to record that the woman has attended her appointment but was not screened, with an appropriately detailed comment, citing reason code NS7.

2.8 Equipment Failure (NS8)

In the event of equipment failure, services will make every effort to contact women in advance, but it may not be possible to contact all women before they attend for their appointment. The equipment failure may have occurred mid-clinic whilst women are in the waiting room.

In this situation, the mammographer would ask the woman whether she would like another appointment to be arranged for a future date whilst she is still at the screening unit. Depending on local practices and whether there is live access to NBSS, this may either be completed directly by the mammographer or by telephoning the screening office.

If no appointment is booked, the woman should be given a copy of the attended not screened client information, annotated appropriately by the mammographer and be advised that she will be issued with another screening appointment. The mammographer must update NBSS to record that the woman has attended her appointment but was not screened, with a comment added to explain that it was due to equipment failure citing reason code NS8.

When reconciling the clinic, the breast screening administration team will rebook a timed appointment as a ‘hospital’ appointment and resend an invitation to all affected women.

[See separate Attended Not Screening Client Information Sheet – for uploading as a supporting document to the guidance]