Rule 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 290-5-22 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 andexperience 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. Basicradiological 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 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 imaginginterpretations 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 procedureunless 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.Ga. Comp. R. & Regs. R. 111-8-40-.24
O.C.G.A. §§ 31-7-2.1 and 31-13-1et seq.
Original Rule entitled "Imaging and Therapeutic Radiology Services" adopted. F. Feb. 20, 2013; eff. Mar. 12, 2013.