6 Colo. Code Regs. § 1011-1 Chapter 04, pt. 18

Current through Register Vol. 47, No. 20, October 25, 2024

Part 18 - NUCLEAR MEDICINE SERVICES

18.1 The hospital may provide nuclear medicine services. If a hospital provides nuclear medicine services, the services must meet the needs of the patients in accordance with acceptable standards of practice.

(A) Nuclear medicine services must be ordered only by practitioners whose scope of federal or state licensure and defined staff privileges allow such referrals.

(B) The governing body and medical staff may also authorize practitioners who do not have hospital clinical privileges to order such studies or procedures, as permitted under state law.

18.2 Nuclear medicine services shall be directed by under the direction of a physician qualified in nuclear medicine.

18.3 The qualifications, training, functions, and responsibilities of the nuclear medicine personnel must be specified by the physician director and approved by the medical staff.

18.4 Nuclear medicine services, including the preparation, labeling, use, transportation, storage, and disposal of radioactive materials shall comply with 6 CCR 1007-1, Rules and Regulations Pertaining to Radiation Control.

18.5 There shall be written policies and procedures for all services offered, based on nationally-recognized guidelines and standards of practice that address, at a minimum, the following:

(A) The qualifications necessary to prepare and/or oversee in-house radiopharmaceuticals, if applicable.

(B) Steps to take in the event of an adverse reaction.

(C) Protection from non-therapeutic radiation exposure for patients and visitors while in the hospital.

(D) Information to be provided to patients who receive nuclear medicine therapy and still have radioactive particles in their bodies regarding how to prevent and/or minimize radiation exposure of others.

18.6 The hospital must maintain signed and dated reports of nuclear medicine interpretations, consultations, and procedures, and maintain copies of all nuclear medicine reports as part of the patient's medical record in accordance with Part 10 of this Chapter.

18.7 The hospital must maintain records of the receipt and distribution of radiopharmaceuticals.

6 CCR 1011-1 Chapter 04, pt. 18