New Mexico Administrative Code › Title 8 - SOCIAL SERVICES › Chapter 370 - OVERSIGHT OF LICENSED HEALTHCARE FACILITIES AND COMMUNITY BASED WAIVER PROGRAMS › Part 12 - REQUIREMENTS FOR ACUTE CARE, LIMITED SERVICES AND SPECIAL HOSPITALS › Section 8.370.12.32 - RADIOLOGICAL SERVICES

Current through Register Vol. 35, No. 13, July 16, 2024
A.
Diagnostic X-Ray services.
(1)
				Requirement: The hospital shall make diagnostic x-ray services available. These
				services shall meet professionally approved standards for safety and the
				qualifications of personnel in addition to the requirements set out in this
				subsection.
(2) Location: The
				hospital shall have diagnostic x-ray facilities available in the hospital
				building proper or clinic or medical facility that is readily accessible to the
				hospital's patients, physicians and staff.
(3) Policies: Written policies and procedures
				shall be developed and maintained by the person responsible for the service in
				consultation with other appropriate health professionals and administration.
				The governing body shall approve the policies. The administrative and medical
				stall shall approve the procedures where appropriate.
(4) Safety:
(a) The radiological service shall be free of
				hazards for patients and personnel.
(b) Proper safety precautions shall be
				maintained against fire and explosion hazards, electrical hazards and radiation
				hazards.
(c) Hospital x-ray
				facilities shall be inspected by a qualified radiation physicist or by the New
				Mexico environment department radiation consultant at least once every two
				years. Hazards identified by inspections shall be properly and promptly
				corrected.
(d) Radiological
				equipment and radiation services shall conform with the requirements of the
				Radiation Protection Act, Sections 74-3-1 through 74-3-16, NMSA 1978.
(e) Attention shall be paid to current safety
				design and good operating procedures for use of fluoroscopes. Records shall be
				maintained of the output of all fluoroscopes.
(f) Policies based on medical staff
				recommendations shall be established for the administration of the application
				and removal of radium element, it's disintegration products and other
				radioactive isotopes.
(5)
				Personnel:
(a) A physician shall have overall
				responsibility for the radiological service. This physician shall be certified
				or eligible for certification by the American board of radiology. If such a
				radiologist is not available on a full-time or regular part-time basis, a
				physician, with training and experience in radiology, may administer the
				service. In this circumstance, a radiologist, qualified as above, shall provide
				consultation services at suitable intervals to assure high quality
				service.
(b) A sufficient number of
				personnel capable of supervising and carrying out the radiological services
				shall be provided. Their training must conform to the requirements set out in
				the Medical Radiation Health and Safety Act, Sections 61-14E-1 through
				61-15E-12, NMSA 1978 and regulations promulgated by the New Mexico environment
				department titled radiologic technology certification, 20.3.20 NMAC.
(c) The interpretation of radiological
				examinations shall be made by physicians qualified in the field.
(d) The hospital shall have a board-certified
				radiologist, full-time, part time or on a consulting basis, who is qualified to
				interpret films that require specialized knowledge for accurate
				reading.
(e) A technologist shall
				be on duty or on call at all times.
(f) Only personnel designated as qualified by
				the state radiology technologist licensing body may use the x-ray apparatus,
				and only similarly designated personnel may apply and remove the radium
				element, its disintegration products and radioactive isotopes. Only properly
				trained persons authorized by the medical director of the radiological service
				may operate fluoroscopic equipment.
(6) Records:
(a) Authenticated radiological reports shall
				be filed in the patient's medical record.
(b) Written orders by the attending physician
				or other individual authorized by medical staff for an x-ray examination shall
				contain a concise statement of the reason for the examination.
(c) Interpretations of x-rays shall be
				written or dictated and signed by a qualified physician or other individual
				authorized by the medical staff.
(d) Copies of interpretive findings shall be
				retained in the medical record for at least 10 years. Scans and other image
				records shall be retained for at least four years.