R432-100-22. Radiology Services

  (1) Each hospital shall provide an organized radiology department offering services that are in accordance with the needs and size of the institution.

  (a) Administrative direction of radiology services shall be provided by a person appointed and authorized by the hospital administrator.

  (b) Medical direction of the department shall be provided by a member of the medical staff.

  (i) If a radiologist is not the medical director of the radiology services, the services of a radiologist shall be retained on a part-time basis.

  (ii) If a radiologist provides services on less than a full-time basis, the time commitment shall allow the radiologist to complete the necessary functions to meet the radiological needs of the patients and the medical staff.

  (c) The radiologist is responsible to:

  (i) maintain a quality control program that minimizes unnecessary duplication of radiographic studies and maximizes the quality of diagnostic information available;

  (ii) develop technique charts that include part, thickness, exposure factors, focal film distances and whether a grid or screen technique; and

  (iii) assure the availability of information regarding the purpose and yield of radiological procedures and the risks of radiation.

  (d) At least one licensed radiologic technologist shall be on duty or available when needed.

  (e) Diagnostic radiology services shall be performed only at the request of a member of the medical staff or other persons authorized by the hospital.

  (f) If radiation oncology services are provided, the following applies:

  (i) Physicians and staff who provide radiation oncology services have delineated privileges;

  (ii) The medical director of the radiation oncology services is a physician member of the medical staff who is qualified by education and experience in radiation oncology.

  (2) Radiologic patient records shall be integrated with the hospital patient record.

  (a) All requests for radiologic services shall contain the reasons for the examinations.

  (b) Authenticated reports of these examinations shall be filed in the patient's medical record as soon as possible. Radiological film shall be retained in accordance with hospital policy.

  (c) If requested by the attending physician and if the quality of the radiograph permits, the radiology department may officially enter the interpretations of the radiologic examinations performed outside of the hospital in the patient's medical record.

  (d) Radiotherapy summaries shall be filed in the patient's medical record. A copy may be filed in the radiotherapy department. The radiotherapy summary shall be forwarded to the referring physician. Unless otherwise justified, the medical record of the patient receiving radiotherapy for treatment or palliation of a malignancy shall reflect the histologically substantiated diagnosis.