18.1 History, Consent, Time-Out, Setup, and Postprocedure Instructions
Key Takeaways
- ARRT's 2025 Mammography outline added patient-preparation detail under Procedures 2.D: pertinent history, informed consent, time-out, set-up, and postprocedure instructions.
- The mammographer verifies a complete consent and participates in the time-out; the performing physician obtains informed consent and performs the invasive steps.
- Time-out confirms correct patient, procedure, laterality, and site with the full team immediately before starting.
- Postprocedure teaching covers ice, expected bruising, hematoma watch, and when to call for expanding swelling or bleeding that does not stop with pressure.
- Sentinel node mapping, cyst aspiration, and fine-needle aspiration biopsy were removed from Procedures in 2025 and are not current mammography exam procedures.
Why This Matters on the 2025 Exam
ARRT's Mammography Content Specifications effective September 1, 2025 added patient-preparation detail under Procedures 2.D. Older outlines treated interventional work as a short list of procedures. The current exam expects you to walk a case from pertinent history through informed consent, a time-out, procedure set-up, and postprocedure instructions. The ARRT footnote on this cluster is basic knowledge of these examinations and procedures: the mammographer assists, positions, images, labels, and keeps the patient safe. The physician obtains consent and performs the needle work.
The 2025 Task Inventory matches that split. You prepare by verifying informed consent as necessary, participating in the preprocedural time-out, and using sterile or aseptic technique when indicated. You then assist with ultrasound or stereotactic core biopsy with clip placement and with wire localization. You perform the associated imaging (specimen, clip, and localization films) covered in later sections of this chapter.
A 2025 content trap sits right next to this material. ARRT removed sentinel node mapping, cyst aspiration, and fine-needle aspiration (FNA) biopsy from Procedures. Do not study those three as current mammography interventional procedures. If an older textbook still lists them under mammography tasks, treat that page as outdated for this exam.
Pertinent History
History for an interventional case is shorter than a screening intake and more focused on bleeding, allergy, and whether today's target and laterality are unambiguous.
Anticoagulation and bleeding risk. Document warfarin, direct oral anticoagulants, heparin products, dual antiplatelet therapy, aspirin when the physician cares about it, and known bleeding disorders. The mammographer's job is to find it and say it out loud, not to independently tell the patient to stop a prescribed anticoagulant. Holding or continuing medication is a physician decision. A patient who mentions clopidogrel only after they are already compressed on a prone table is a stop-and-communicate case, not a "we are already set up" case.
Allergies. Screen for lidocaine (and other local anesthetics), latex, and iodinated contrast if contrast will actually be used. Routine stereotactic and ultrasound core biopsy do not include intravascular contrast. If the day's plan does involve contrast, a prior reaction belongs in the time-out. Latex allergy changes gloves and some supplies before the tray is opened. Anesthetic allergy is not solved by "using a little less"; the physician chooses an alternative plan.
Also note breast implants, prior ipsilateral surgery or radiation, inability to lie prone or sit still, a strong vasovagal history, and pregnancy when relevant. Confirm which breast, which clock position or quadrant, and whether the target is calcifications, a mass, a clip, or a post-biopsy cavity. Pull the prior images into the room so the time-out is matching today's patient to today's finding, not to a sticky note on the monitor.
Informed Consent
Informed consent is a process: the performing physician (or qualified delegate under facility policy) discloses the nature of the procedure, material risks, benefits, and alternatives, and the patient agrees. Typical risks the physician covers include bleeding and hematoma, infection, a missed or undersampled lesion, clip migration, skin injury, and vasovagal reaction. Alternatives may include surgical biopsy or imaging follow-up. A signature without that discussion is not informed consent.
The mammographer verifies that a complete form is present, matches today's procedure and laterality, is signed and dated, and that the patient still agrees before the time-out. If the form says right breast biopsy and the order, images, and skin mark are left, the case does not start. If the patient suddenly asks "could this spread the cancer?" while you are opening lidocaine, stop and bring the physician back. Those questions are consent questions, not small talk during skin prep.
Consent is not the mammographer's independent risk-disclosure lecture. ARRT scenario items often offer "the technologist quickly reviews the risks while setting up so the physician can stay in clinic" as a distractor. That is the wrong role split.
Time-Out
The time-out is the breast-imaging application of The Joint Commission's Universal Protocol. It happens immediately before the invasive step, in the room where the procedure will occur, with the team pausing for active communication. Check-in at the front desk is not a time-out.
| Element | What the team verifies out loud |
|---|---|
| Correct patient | Two identifiers (name plus date of birth or medical record number) |
| Correct procedure | Core biopsy versus wire localization versus clip-related imaging, matching the order |
| Correct laterality | Right versus left breast |
| Correct site | Clock position, quadrant, or other documented landmark |
| Matching images | Prior mammograms or ultrasound labeled for this patient and this finding |
Allergies and anticoagulation belong in the same pause. Any mismatch stops the case until it is reconciled. "She told me in the waiting room which breast it is" does not replace laterality verification against the order and the images.
Procedure Set-Up and Positioning
Set-up means a sterile (or appropriately aseptic) field, skin antisepsis, the correct probe or needle system, specimen containers labeled before tissue is obtained, and positioning that actually puts the target in reach.
- Stereotactic prone: patient face-down, breast through the table aperture, compressed in the biopsy window. Confirm the finding is in the window on the scout before anyone opens the skin.
- Stereotactic upright: sitting or lateral decubitus on a dedicated or add-on unit. Posterior lesions are often easier to reach. Vasovagal reactions are more common because the patient can see the needle.
- Ultrasound: typically supine or posterior oblique, ipsilateral arm raised. Document the mass in two planes before prep. Use a probe cover, sterile gel, and a controlled field — ultrasound is not an excuse for a dirty tray.
Choose an approach that reaches the lesion, respects implants and the chest wall, and leaves an adequate stroke margin (enough tissue beyond the target so the needle throw does not exit the far skin). If the calculated trajectory would exit the breast, you do not fire. Change projection, compression, or needle geometry until the margin is safe. Details of targeting coordinates belong with stereotactic and ultrasound-guided biopsy.
Stay with the patient after local anesthetic. Vasovagal reactions present as pallor, sweating, nausea, or syncope. Stop, get the needle out of a dangerous position, restore perfusion per facility protocol (often reclining with legs elevated), and do not leave the patient unattended on an upright chair.
Mammographer Versus Physician Roles
| Task | Physician | Mammographer |
|---|---|---|
| Informed-consent discussion | Obtains | Verifies a complete, laterality-matched form |
| Targeting decision and needle path | Directs | Positions the patient; obtains scout, stereo, or real-time ultrasound images |
| Local anesthetic, incision, sampling, clip | Performs | Assists, maintains the field, manages specimens |
| Adequacy of cores | Decides | Images cores and reports what the radiograph shows |
| Results counseling | Physician/team | Delivers wound-care instructions and the when-to-call list |
You may — and must — stop a wrong-site case. You may not deploy a clip because the physician stepped out "for a second."
Postprocedure Instructions
After sampling and clip placement, hold firm compression, dress the nick, and give instructions the patient can repeat back.
- Ice: over a cloth barrier, in short intervals during the first several hours, as the facility instructs.
- Activity: avoid strenuous exercise and heavy lifting for about 24–48 hours per protocol; keep the dressing dry.
- Expected: mild bruising, tenderness, and a small lump at the site.
- Hematoma watch: a rapidly enlarging, firm, painful swelling, or bleeding that soaks the dressing and does not stop with pressure, is not "normal bruising."
- When to call: expanding hematoma or uncontrolled bleeding; fever, spreading redness, warmth, or drainage in the following days; syncope, chest pain, or shortness of breath; a localization wire that pulls back or snaps before surgery.
Explain that a metallic clip is a marker, not a treatment, and tell the patient how biopsy results will be communicated. The 2025 Patient Care outline separately emphasizes the results process; interventional postprocedure talk should not contradict it.
Realistic Exam Scenario
A patient arrives for a left-breast stereotactic biopsy of calcifications. The consent in the jacket is signed for a right-breast ultrasound core biopsy from last month. The mammographer who "goes ahead because the patient says it is the left side today" has skipped both consent verification and time-out. The correct next step is to stop, obtain a consent that matches today's procedure and laterality, and only then perform the time-out.
Common Traps
- Studying sentinel node mapping, cyst aspiration, or FNA biopsy as current Procedures 2.D items.
- Treating consent as a signature the mammographer can harvest while opening the tray.
- Skipping laterality in the time-out because the patient "knows which breast."
- Independently holding anticoagulants instead of reporting them to the physician.
- Sending a patient home without a hematoma warning because "it is just a nick."
Immediately before a stereotactic core biopsy, which action best satisfies the preprocedural time-out expected on the ARRT Mammography exam?
For an image-guided breast core biopsy, who is responsible for obtaining informed consent?
Which postprocedure finding should prompt the patient to call immediately rather than being treated as expected bruising?