New York Codes, Rules and Regulations › Title 10 - DEPARTMENT OF HEALTH › Chapter V - Medical Facilities › Subchapter A - Medical Facilities-minimum Standards › Article 2 - Hospitals › Part 405 - Hospitals-Minimum Standards › Section 405.15 - Radiologic and nuclear medicine services

Current through Register Vol. 46, No. 28, July 10, 2024
(a)
General provisions for diagnostic
					 and therapeutic radiologic services.
The hospital shall maintain or have available diagnostic
						radiologic services defined for purposes of this subdivision as imaging
						services utilizing diagnostic radiation equipment or devices which emit
						radiation by virtue of the application of high voltage. If therapeutic services
						are provided, they shall meet the requirements established in subdivision (b)
						of this section in addition to the requirements of this subdivision. In
						addition, the hospital shall meet the standards of Part 16 of the State
						Sanitary Code.
(1) The hospital shall
					 maintain or have available radiologic services according to the needs of the
					 patients as determined by the governing body in consultation with the medical
					 staff and the administration.
(2)
					 Radiologic services shall be provided in accordance with generally accepted
					 standards of practice only on the order of physicians or, consistent with State
					 law, of those other practitioners authorized by the medical staff and governing
					 body to order such services.
(3)
					 Safety for patients and personnel.
Written policies and procedures shall be developed and
						implemented and available for review. The policies and procedures regarding
						imaging studies for newborns and pediatric patients shall include standards for
						clinical appropriateness, appropriate radiation dosage and beam collimation,
						image quality and patient shielding. A policy and a procedure shall be
						developed to ensure that the practitioner's order for an imaging study is
						specific as to the body part(s) that are to be imaged.
Quality improvement audits shall verify that these
						policies and procedures are being followed. Quality improvement activities
						shall include a review of the adequacy of diagnostic images and
						interpretations.
(i) Proper safety
					 precautions shall be maintained against fire and explosion hazards, electrical
					 hazards and radiation hazards. This includes adequate shielding for patients
					 and personnel, as well as appropriate storage, use and disposal of radioactive
					 materials.
(ii) Any existing or
					 potential hazards identified through periodic inspection by local or State
					 health authorities shall be corrected promptly.
(iii) Personnel shall be instructed in
					 radiation safety principles and practices. The radiation safety principles
					 shall be adequate to ensure compliance with all generally accepted standards of
					 practice as well as pertinent laws, rules and regulations. Policies and
					 procedures shall be developed to minimize the radiation exposure that is
					 necessary to produce high quality imaging studies on patients of all
					 ages.
(iv) Radiologic procedures
					 requiring the use of contrast media or fluoroscopic interpretation and control
					 shall be performed with the active participation of a qualified specialist in
					 diagnostic radiology or a physician qualified in a medical specialty related to
					 the radiographic procedure. Emergency equipment and staff trained in its use
					 shall be available for anaphylactic shock reactions from contrast
					 media.
(4) Personnel.
The hospital shall provide qualified personnel adequate
						to supervise and conduct the services. For radiologic tests, the following
						personnel standards shall apply for the purposes of this subdivision:
(i) a full-time or part-time radiologist who
					 is board certified or board admissible in radiology shall direct the clinical
					 aspects of the organization and delivery of radiologic services. That
					 radiologist or another individual qualified by education and experience shall
					 direct the administrative aspects of the services;
(ii) radiologic tests shall be interpreted by
					 a board certified or board admissible radiologist, except that radiologic tests
					 may be interpreted by practitioners within their field of specialization who
					 are granted privileges to interpret such tests by the governing body and the
					 medical staff in consultation with the director of radiologic services pursuant
					 to the credentialing process in the hospital;
(iii) the services of qualified radiologists,
					 qualified practitioners, and licensed radiologic technologists shall be
					 sufficient and available to meet the needs of the patients. A licensed
					 technologist shall be on duty or available at all times and function in
					 accordance with article 35 of the Public Health Law and Part 89 of this
					 Title;
(iv) use of the radiologic
					 equipment and administration of radiologic procedures shall be limited to
					 personnel who are currently licensed and designated as qualified by the
					 hospital in accordance with any applicable licenses and regulations.
(v) The chief of radiology, in conjunction
					 with the radiation safety officer, shall ensure that all practitioners who
					 utilize ionizing radiation equipment within the hospital are properly trained
					 in radiation safety procedures for patients of all ages.
(5) Records.
Records of radiologic services including interpretations,
						consultations and therapy shall be filed with the patient's record, and
						duplicate copies shall be kept in the radiology department/service. All films,
						scans and other image records shall be referenced in the patient's medical
						record and retained in the patient's medical record, radiology
						department/service or in another central location accessible to appropriate
						staff. All electronic images shall have a duplicate storage either offsite or
						in another area of the hospital separate from the primary storage
						devices.
(i) Requests by the attending
					 practitioner for X-ray examination shall contain a concise statement of reasons
					 for the examination which shall be authenticated by the requestor.
(ii) The radiologist or other practitioner
					 who performs radiology services shall authenticate reports of his or her
					 interpretations.
(iii) The hospital
					 shall retain films, scans and other image records which have not been
					 incorporated in the medical record for at least six years or three years after
					 a minor patient reaches the age of majority.