Document ID: chunk:federal_register_of_legislation:F2020L00351:schedule:1:p4
Version: federal_register_of_legislation:F2020L00351
Segment Type: schedule
Provision Reference: sch 1 (pt 4/7)
Character Range: 35441–38825

imaging procedures. (Standard 1.1)
    •          a sample of de-identified requests documenting the clinical need for the diagnostic imaging procedures rendered at the diagnostic imaging practice.

For practitioners providing self-determined services:
    •          a sample of de-identified records documenting clinical need.

Standard 2.2   Consumer Consent and Information Standard

Prior to a diagnostic imaging procedure being rendered, except in cases of emergency, the diagnostic imaging practice must ensure that:

    a)      patients have access to information about the diagnostic imaging procedure;

    b)      risks are advised to the patient or substitute decision maker;

    c)      practice staff obtain and record relevant information about the patient's health status and individual patient risk factors;

    d)      consent for each diagnostic imaging procedure is obtained from the patient or the substitute decision maker; and

    e)      patient consent requirements reflect the risk attached to the diagnostic imaging procedure.

Required Evidence

A documented policy and procedure for obtaining patient consent prior to a diagnostic imaging procedure being provided, ensuring that the consent requirements reflect the level of risk attached to each procedure. It is expected that practices obtain written patient consent prior to invasive or high risk procedures. (Standard 1.1)

A sample of de-identified records of consent obtained from the patient in respect of the diagnostic imaging procedure.

A sample of de-identified records documenting the patient's health status, relevant to the diagnostic imaging procedure being undertaken, with regard to:
    -          asthma;
    -          previous exposure to intravenous contrast;
    -          allergies;
    -          medical conditions such as diabetes, kidney disease or heart disease;
    -          pregnancy status;
    -          medications such as metformin hydrochloride;
    -          breastfeeding; and
    -          medical devices and implanted devices such as intra- cranial aneurysm clips, cardiac pacemaker, coronary stents, intra ocular foreign bodies and cochlear implants.

Examples of service specific information for the diagnostic imaging services available at the practice.

A sample of de-identified records must be provided which demonstrate that risks have been advised to the patient.

Standard 2.3   Patient Identification & Procedure Matching Standard

The diagnostic imaging practice must ensure that all patients are correctly identified and matched to their intended procedure or treatment by:

    a)      using at least three (3) approved patient identifiers to match a patient to their request or medical record from the time the patient presents and through all stages of the diagnostic imaging service and when transferring responsibility of care;

    b)      correctly matching patients with their intended diagnostic imaging service and the anatomical site and side (if applicable) of the diagnostic imaging procedure;

    c)      utilising the 'time-out' technique for high risk procedures, including confirming the patient's allergy status; and

    d)      reporting, investigating, and responding to patient care mismatching events when they occur and implementing changes, where relevant, to reduce the risk of future incidents.

Required Evidence