Section 518.2010  Radiological Services

a)         The freestanding emergency center shall maintain and provide radiological services sufficient to perform and interpret the radiological examinations necessary for the diagnosis and treatment of patients, to the extent that the complexity of services is commensurate with the size and scope of the FEC. Additional required services shall be provided by shared services or referral of patients.

b)         The physician responsible for the direction of a radiological department or service shall be Board certified or eligible for certification by the American Board of Radiology or equivalent.  The physician shall have a written agreement with the FEC to direct the Radiological Services on a full-time, part-time or consulting basis and be an approved member of the medical staff. The responsibilities of the physician must be identified in a policy and procedures manual or other document.

c)         Technicians employed in the radiological services shall have had sufficient training and experience to carry out the procedures safely and efficiently commensurate with the size and scope of the service.  A procedure and means for evaluating qualifications shall be established and used.

d)         Radiological services shall be available at all times.

e)         Complete, signed reports of the radiological examinations shall be made part of the patient's record, and duplicate copies shall be kept in the department for a period of time established by the FEC.

f)          Written reports of each radiological interpretation, consultation and treatment shall be signed by the physician responsible for conducting the procedure and shall be a part of the patient's medical record.  Maintenance and filing of records should be coordinated with direction and supervision by the Medical Record Administrator.

g)         X-ray or roentgen photographs shall be retained in accordance with the X-ray Retention Act [210 ILCS 90], which requires retention for five years and longer where notification of litigation is received.

h)         Radiological facilities operated by an FEC constitute a "radiation installation" within the meaning of the Radiation Installations Act [420 ILCS 30] and are required to be registered with the Department of Nuclear Safety.

i)          Each radiological department or identified distinct radiological service shall prepare and maintain a policies and procedures manual, which shall be reviewed and updated annually and shall include, but not be limited to, provision for the following identified requirements:

1)         The FEC shall establish and enforce safety regulations that will protect both patient and radiological worker from excessive or stray radiation.

2)         Where radiation hazard exists, the FEC shall periodically obtain a survey and report by a qualified radiation physicist indicating that satisfactory conditions exist.

3)         Personnel Monitoring

A)        Procedures for personnel monitoring shall be maintained for each individual working in the area of radiation where there is a reasonable probability of receiving one-fourth of the maximum permissible dose.

B)        Personnel monitoring records resulting from the use of film badges or dosimeters must be maintained. Readings must be on at least a monthly basis.

C)        Upon termination of employment, each worker should be provided with a summary of his exposure record.

D)        Permanent records of exposure on all monitored personnel must be maintained for review by surveyors for licensing.

4)         Monthly and yearly reports shall be maintained on the number of examinations done and kinds of treatment given.

5)         The use of all radiological apparatus shall be limited to personnel designated as qualified by the physician responsible for the direction and/or supervision of the department or service.  The use of fluoroscopes shall be limited to credentialed physicians.

6)         Participation in continuing education by all radiological personnel (including physicians responsible for the direction and supervision of radiological services) shall be documented.

7)         A current interesting case file should be maintained on a regular basis for educational purposes.

8)         At all times, reasonable privacy shall be provided for the radiological patient relative to dressing, evacuation, and the study being performed.

9)         Safety rules shall be written for the radiological services to protect patients and personnel.  These rules must relate to radiation, electrical and mechanical hazards, prevention and containment of fire and explosion, and prevention and treatment of any untoward reaction to contrast media.

10)       Written policies and procedures must be enforced for the radiological services that relate to the management of critically ill patients and to the administration of diagnostic agents by nonphysicians.

11)       When nonphysicians are permitted to administer diagnostic agents intravenously for radiological evaluations, written safety guidelines must specify which individuals have this authority and require that a physician be immediately available.

12)       An emergency drug tray must always be present in the room or immediately available where parenteral diagnostic agents for radiologic evaluations are being administered.  A system shall be established for maintaining an emergency drug tray with appropriate content and no outdated medications or missing items.  Oxygen, airways, syringes and needles, intravenous administration sets, and appropriate parenteral solutions shall be available at all times.

13)       Written safety rules must provide:  for the steps to be followed in the event of a spill of radioactive material; for specific authority for any nonphysician personnel who administer isotopes intravenously; for the recording of cumulative radiation exposure of all personnel; a requirement for protective security from all radioacative areas for all unauthorized personnel; and the establishment of a radiation protection survey at least every six months.

14)       Instrument log books maintained by Radiological Services must include calibration records of equipment and monitors, maintenance and repair records, and the findings of outside evaluators (if used), with the corrective action taken.