Ga. Comp. R. & Regs. R. 111-8-40-.24 - Imaging and Therapeutic Radiology Services
(1)
Imaging Services. The hospital shall maintain or arrange for effective imaging
services to meet the needs of patients. The radiological imaging services shall
be provided by the hospital in accordance with the rules under Chapter 111-8-90
Rules and Regulations for X-rays, where applicable.
(a) Organization and Staffing for Imaging
Services. The hospital shall have an organizational plan for imaging services
that identifies the scope of the services provided and the qualifications of
the individuals necessary for the performance of various aspects of imaging
services and delineates the lines of authority and accountability.
1. There shall be a qualified director of
imaging services who is a member of the medical staff and a licensed doctor of
medicine or osteopathy with knowledge and experience in imaging services to
supervise the provision of imaging services on a full-time or part-time
basis.
2. The director shall be
responsible for all clinical aspects of the organization and delivery of
imaging services, including the evaluation of the effectiveness of the services
in coordination with the hospital's quality management program.
3. Basic radiological imaging services shall
be available at all times, or there shall be an on-call procedure to provide
access to qualified x-ray personnel within thirty (30) minutes.
4. The hospital shall have qualified staff
performing imaging services.
(b) Orders of Imaging Procedures. No imaging
procedures, except screening mammograms, shall be performed without an order or
referral from a licensed doctor of medicine or osteopathy, chiropractor,
dentist, podiatrist, physician assistant or nurse with advanced training where
such order is in conformity with an approved job description or nurse protocol,
and as authorized under state law for such licensed healthcare
professionals.
(c) Verbal/telephone
orders for imaging services shall be given only to health care professionals
licensed or certified by state law or authorized by medical staff rules and
regulations and other hospital policy to receive those orders, in accordance
with these rules, and shall be entered into the patient's medical record by
those licensed, certified, or authorized health care professionals.
(2) Reports of Imaging
Interpretations. Interpretation of imaging test results or procedures shall be
made only by those medical staff designated as qualified to interpret those
tests or procedures. Interpretations must be signed and dated by the medical
staff providing the interpretation.
(a)
Reports of all imaging interpretations and consultations shall be included in
the patient's medical record.
(b)
The hospital shall have an effective procedure for notifying in a timely manner
the patient's physician and responsible nursing staff of critical
interpretations identified through imaging tests.
(c) Films, scans, and other images shall be
retained by the hospital for at least five years after the date of the
procedure unless the release of the original images is required for the care of
the patient. When original images are released, documentation of the
disposition of the original images shall be retained for the applicable
five-year period. If the patient is a minor, the records shall be retained for
at least five years past the age of majority.
(3) Therapeutic Radiology Services. Radiation
oncology services, if provided, must be directed by a physician with training
and experience in therapeutic radiology. The service must have a medical
oncologist and hematologist available for consultation.
(a) Therapeutic radiology procedures shall be
ordered by a licensed Doctor of Medicine or osteopathy and administered by
persons trained and qualified for those procedures and as required under
current state law and regulations.
(b) Reports of all imaging interpretations,
consultations, and therapies shall be included in the patient's medical
record.
(c) Radiation Safety. If
the hospital is providing diagnostic or therapeutic radiological services,
hospital policies and procedures shall be implemented to ensure that patients
and hospital staff are not exposed to unnecessary or unsafe levels of
radiation. All imaging staff and therapeutic radiology staff shall be trained
in these policies and procedures.
(d) Medical Emergencies. The hospital shall
have written protocols for managing medical emergencies in the imaging area and
therapeutic radiology area.
(e)
Infectious Disease. The hospital shall have written protocols for managing
patients with infectious diseases and critical care patients in the imaging
area, or wherever imaging services are provided, and in the therapeutic
radiology area.
Notes
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No prior version found.