Section 250.630  General Policies and Procedures Manual

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

a)         The hospital shall establish and enforce safety regulations which will protect both patient and radiological worker from excessive or stray radiation.

b)         Where radiation hazard exists the hospital shall periodically obtain a survey and report by a qualified radiation physicist indicating satisfactory conditions exist.

c)         Personnel Monitoring

1)         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.

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

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

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

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

e)         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.

f)          There shall be documentation of participation by all radiological personnel (including physicians responsible for the direction and supervision of radiological services) in continuing education.

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

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

i)          There must be written safety rules 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.

j)          There must be enforced written policies and procedures for the radiological services which relate to the management of critically ill patients and to the administration of diagnostic agents by nonphysicians.

k)         When nonphysicians are permitted to administer diagnostic agents intravenously for radiological evaluations, there should be written safety guidelines specifying which individuals have this authority and requiring that a physician be immediately available.

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

m)        Policies and procedures for the administration of drugs shall be coordinated with and approved by the Pharmacy and Therapeutics Committee.  (Refer to Subpart R Section 250.2140).

n)         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 radioactive areas for all unauthorized personnel; and the establishment of a radiation protection survey at least every six months.

o)         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.

p)         It is recommended that requests by attending members of the medical staff for radiological examinations contain a concise statement of the reason for the examination.

(Source:  Amended at 5 Ill. Reg. 507, effective December 29, 1980)