Idaho Admin. Code r. 16.03.14.430

Current through September 2, 2024

Section 16.03.14.430 - NUCLEAR MEDICINE SERVICES

If appropriate for the hospital the use of internal radionuclides for diagnosis and treatment of patients may be established.

01.Nuclear Medicine Staffing. If the hospital has nuclear medical service, medical care shall be under the overall direction of a qualified nuclear medicine physician. The physician shall provide direction for:

a. Determination of qualifications of all other personnel in the service; and

b. Organizational structure and personnel needed; and

c. Establishing a procedure for assuring physician coverage; and

d. Continuing education for all staff.

02.Policies and Procedures. Written policies and procedures, approved by the physician director in consultation with other appropriate professionals and administration, shall be developed and implemented. Policies and procedures shall include but shall not be limited to:

a. Policies and procedures for the preparation, use, storage, disposition, and labeling of all radioactive materials; and

b. Quality control procedures to ensure proper identity, strength, and purity of all radiopharmaceutical agents; and

c. Procedures for the testing, use, calibration, and preventive maintenance of all equipment; and

d. A policy stating the responsibility of the nuclear medicine staff to the medical staff.

03.Facilities. Nuclear medicine services shall be provided in an area that is appropriately equipped for the scope of services, and is safe for both patients and personnel.

04.Radiation Control. The nuclear medicine service shall comply with Sections 39-3001 through 39-3019, Idaho Code.

05.Records. Signed and dated requests, reports, and records of diagnostic and therapeutic procedures shall be incorporated into the patient's medical record, and copies shall be kept on file in the nuclear medicine department. Records shall contain at least the following:

a. Patient identification; and

b. Reason for diagnostic or treatment request; and

c. A record of all radiopharmaceuticals that shall include:

i. Date; and

ii. Identity; and

iii. Supplies and lot number; and

iv. Amounts administered.

d. All records of equipment or monitor testing, repair, and calibration.

06.Nuclear Medicine Reviews. The medical staff or a committee of the staff shall review nuclear medicine services as needed, but not less than annually.

Idaho Admin. Code r. 16.03.14.430

Effective March 17, 2022