N.M. Admin. Code § 8.370.12.33 - NUCLEAR MEDICINE SERVICES
A.
Nuclear medicine service:
(1) Requirement: If a hospital provides
nuclear medicine services, the services shall meet the needs of the hospital's
patients in accordance with acceptable standards of professional
practice.
(2) Organization and
staffing:
(a) the organization of the nuclear
medicine services shall be appropriate for the scope and complexity of the
services offered;
(b) there shall
be a physician director who is qualified in nuclear medicine to be responsible
for the nuclear medicine service;
(c) the qualifications, education, training,
functions and legal responsibilities of nuclear medicine personnel shall be
specified by the director of the service and approved by the medical staff and
chief executive officer/administrator based upon the assurance that personnel
are appropriately licensed by the state radiology technologist licensing body;
and
(d) all persons who administer
radiopharmaceuticals shall be approved by the medical staff and in accordance
with applicable federal, state and local laws; the numbers and types of
personnel assigned to nuclear medicine shall be appropriate for the scope and
complexity of the services offered.
(3) Location: Nuclear medicine services shall
be provided in an area of the hospital that is adequately shielded.
(4) Radioactive: Radioactive materials shall
be prepared, labeled, used, transported, stored and disposed of in accordance
with applicable regulations, i.e. the Radiation Protection Act 74-1-9, 74-3-5,
74-39, NMSA 1974, and all regulations promulgated thereunder.
(5) Equipment and supplies:
(a) Equipment and supplies shall be
appropriate for the types of nuclear medicine services offered and shall be
maintained for safe and efficient performance.
(b) All equipment shall be maintained in safe
operating condition and shall be inspected, tested and calibrated at least
annually by a radiation or health physicist.
(6) Records:
(a) Authenticated and dated reports of
nuclear medicine interpretations, consultations and therapy shall be made part
of the patient's medical record and copies shall be retained by the
service.
(b) Records shall note the
amount of radiopharmaceuticals administered, the identity of the recipient, the
supplier and lot number and the date of therapy.
(c) The hospital shall provide for monitoring
the staff's exposure to radiation. The cumulative radiation exposure for each
staff member shall be recorded in the service's records at least
monthly.
(d) Records of the receipt
and disposition of radiopharmaceuticals shall be maintained. Documentation of
instrument performance and records of inspection shall be retained in the
service.
B.
Mobile nuclear medicine services: The use of mobile nuclear
medicine services by a facility to meet the diagnostic needs of its patients
shall be subject to approval of the medical staff and the chief executive
officer/administrator. The services offered by the mobile nuclear medicine unit
shall comply with all applicable rules of this section.
Notes
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