RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY
515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme....
Attach the following documents to the application:
References to Common Program and Institutional Requirements are in pare...
RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY
515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme....
RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY
515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme....
B. PARTICIPATING SITES
SPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility f...
1. Single Program Sponsoring Institutions (Institutions that sponsor a single core or subspecialty
program, or a single co...
C. FACULTY / RESOURCES
1. Program Director Information
Name:
Title:
Address:
City, State, Zip code:
Telephone: FAX: Email:...
3. Faculty Curriculum Vitae
First Name: MI: Last Name:
Present Position:
Graduate Medical Education Program Name(s); inclu...
5. Program Resources
a) How will the program ensure that faculty (physician and nonphysician) have sufficient time to
supe...
THE RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY
515 N State, Suite 2000, Chicago, IL 60654 • (312) 755-5000 • www....
2. Will the fellow have responsibility for teaching residents? ...................................( ) YES ( ) NO
If yes, d...
PROFESSIONALISM
1. Do fellows demonstrate compassion, integrity, and respect for others? (PR IV.A.2.e.(1))
..................
c) At least one interdisciplinary conference per week (IV.A.3.c).........................( ) YES ( ) NO
d) Peer review cas...
FELLOWS’ SCHOLARLY ACTIVITIES
1. Describe how fellows are instructed in the fundamentals of experimental design, performan...
1111RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY
515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.ac...
6. How does the program provide for graduated study, experience and responsibility in the following
areas:
a) nuclear radi...
SPACE AND EQUIPMENT
1. Complete only for sites to which rotations total a minimum of 3 months
Site #1 Site #2 Site #3
Nucl...
TEACHING FILE
1. Total number of cases in institutionally accumulated nuclear radiology file: ( )
2. Does the department h...
TOTAL
Genitourinary
Renal Scan 78707, 78708,
78709
Tumor and Infection
Tumor localization
(planar/Spect)
78800, 78801,
788...
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  1. 1. RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR NEW APPLICATIONS ONLY - NUCLEAR RADIOLOGY GENERAL INSTRUCTIONS APPLICATIONS FOR A NEW PROGRAM: This Program Information Form (PIF) is for programs applying for INITIAL ACCREDITATION ONLY (for Continued Accreditation or re-accreditation, use the CONTINUED ACCREDITATION PIF in conjunction with the Web Accreditation Data System). All sections of the form applicable to the program must be completed in order to be accepted for review. The information provided should describe the proposed program. For items that do not apply indicate N/A in the space provided. Where patient numbers are requested, estimate what you expect will occur. If any requested information is not available, an explanation should be given and it should be so indicated in the appropriate place on the form. Once the forms are complete, number the pages sequentially in the bottom center. Send three complete copies to the executive director of the Residency Review Committee for Diagnostic Radiology at the address above. They must be identical and final. Draft copies are not acceptable. The forms should be submitted bound by either sturdy rubber bands or binder clips. Do not place the forms in covers such as two or three ring binders, spiral bound notebooks, or any other form of binding. The program director is responsible for the accuracy of the information supplied in this form and must sign it. It must also be signed by the designated institutional official of the sponsoring institution. Review the Program Requirements for Residency Education in Nuclear Radiology. The Program Requirements or the Institutional Requirements may be downloaded from the ACGME website (www.acgme.org): For questions regarding: -the completion of the form (content), contact the Accreditation Administrator. -the Accreditation Data System, email WebADS@acgme.org. For a glossary of terms, use the following link – http://www.acgme.org/acWebsite/GME_info/gme_glossary.asp Nuclear Radiology i
  2. 2. Attach the following documents to the application: References to Common Program and Institutional Requirements are in parenthesis 1. Policy for supervision of residents (addresses residents’ responsibilities for patient care and progressive responsibility for patient management and faculty responsibilities for supervision) (CPR IV.A.4.; IR III.B.4.) 2. Program policies and procedures for residents’ duty hours and work environment (CPR II.A.j.4.; CPR VI.C.; IR II.D.4.i.; IR III.B. 3.) 3. Moonlighting policy (CPR VI.F.1-2; CPR II.A.4.j.; IR II.D.4.j.) 4. Overall educational goals for the program (CPR IV.A.1.) 5. A sample of competency-based goals and objectives for one assignment at each educational level (CPR IV. A. 2.) 6. All Program Letters of Agreement (PLAs) (CPR I.B.1.) 7. A blank copy of the forms that will be used to evaluate residents at the completion of each assignment (CPR V.A.1.a.) 8. Copies of tools the program will use to provide objective assessments of competence in patient care, medical knowledge, practice-based learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice (CPR V.A.1.b.(1)) 9. A blank copy of the form that will be used to document the semiannual evaluation of the residents with feedback (CPR V.A.1.b.(2) & (4)) 10. A blank copy of the final (summative) evaluation of residents, documenting performance during the final period of education and verifying that the resident has demonstrated sufficient competence to enter practice without direct supervision (CPR V.A.2.) 11. A blank copy of the form that residents will use to evaluate the faculty (CPR V.B. 3.) 12. A blank copy of the form that residents will use to evaluate the program (CPR V.C.1.d.(1)) Single Program Sponsors only: 1. A copy of the resident contract with the pertinent items from the institutional requirements and Master Affiliation Agreements 2. Institutional policy for recruitment, appointment, eligibility, and selection of residents (IR II.A.) 3. Institutional policy for discipline and dismissal of residents, including due process (IR II.D.4.e.; IR III.B.7.) Nuclear Radiology ii
  3. 3. RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org 10 Digit ACGME Program I.D. #: Program Name: TABLE OF CONTENTS When you have completed the forms, number each page sequentially in the bottom center. Report this pagination in the Table of Contents and submit this cover page with the completed PIF. Common PIF1 Page(s) Accreditation Information Participating Sites Single Program Sponsoring Institutions (if applicable) Faculty/Resources Program Director Information Physician Faculty Roster Faculty Curriculum Vitae Non Physician Faculty Roster Program Resources Fellow Appointments Number of Positions Actively Enrolled Fellows (if applicable) Skills and Competencies Grievance Procedures Medical Information Access Evaluation (Fellows, Faculty, Program) Fellow Duty Hours Common Subspecialty PIF (for subspecialties of Diagnostic Radiology) Page(s) Institutions Program Personnel and Resources Fellow Appointments Patient Care Medical Knowledge Interpersonal and Communication Skills Professionalism Systems-based Practice Curriculum Fellows’ Scholarly Activity Evaluation Specialty Specific PIF Institutional Data Narrative Description Space and Equipment Teaching File Nuclear Radiology Procedures Nuclear Radiology iii
  4. 4. RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR NEW APPLICATIONS ONLY - NUCLEAR RADIOLOGY A. ACCREDITATION INFORMATION Date: Title of Program: Core Program Information Title of Core Program: Core Program Director: 10 Digit ACGME Program ID#: Accreditation Status: Effective Date: Next Review Date: Last Review Date: Cycle Length: The signatures of the director of the program and the Designated Institutional Official attest to the completeness and accuracy of the information provided on these forms: Signature of Program Director (and Date): Signature of Core Program Director (and Date): Signature of Designated Institutional Official (DIO) (and Date): 1. Respond to previous citation(s) Provide a concise update on each previous citation and indicate how each has been addressed (if applicable). 2. Describe changes not mentioned above Provide a concise update explaining any major changes, not described in your response to question # 1, to the fellowship program since the last site visit (for example, changes in program format, fellow complement, program leadership, or participating sites). 3. Planned start date for the first class of fellows (answer only if this is a new application) Nuclear Radiology 1
  5. 5. B. PARTICIPATING SITES SPONSORING INSTITUTION: (The university, hospital, or foundation that has ultimate responsibility for this program.) Name of Sponsor: Address: Single Program Sponsor? ( ) YES ( ) NO City, State, Zip code: Type of Institution: (e.g., Teaching Hospital, General Hospital, Medical School) Name of Designated Institutional Official: Mailing Address: Phone Number: Email: Name of Chief Executive Officer: PRIMARY SITE (Site #1) Name: Address: City, State, Zip Code: Clinical Site? ( ) YES ( ) NO Type of Rotation (select one) Elective ( ) Required ( ) Both ( ) Length of Fellow Rotations (in months) CEO/Director/President’s Name: Joint Commission Accredited? ( ) YES ( ) NO If no, explain: The Program Director must submit any participating sites routinely providing an educational experience, required for all fellows. Duplicate as necessary. PARTICIPATING SITE (Site #2) Name: Address: City, State, Zip Code: Integrated: ( ) YES ( ) NO Does this site also sponsor its own program in this subspecialty? ( ) YES ( ) NO Does it participate in any other ACGME-accredited programs in this subspecialty? ( ) YES ( ) NO Distance between #2 & #1: Miles: Minutes: Type of Rotation (select one) ( ) Elective ( ) Required ( ) Both Length of Fellow Rotations (in months) CEO/Director/President’s Name: Brief Educational Rationale: Nuclear Radiology 2
  6. 6. 1. Single Program Sponsoring Institutions (Institutions that sponsor a single core or subspecialty program, or a single core program and its subspecialties). For those institutions which are either a single-program sponsoring institution (e.g., medical genetics only), or an institution with multiple residencies accredited by the same Residency Review Committee (RRC), the institutional review will be conducted in conjunction with the review of the program. Only programs in these two categories are to complete the following institutional questions. a) Provide an institutional statement that commits the necessary financial, educational, and human resources to support the GME program(s) and provide documentation that the statement has been approved by the governing body, the administration and the teaching staff. (IR I.B.2) b) Describe the formal method by which a periodic evaluation of the program’s educational quality and compliance with the program requirements occurs. Explain how fellows and faculty in the program are involved in the evaluation process. (CPR V.C; IR IV) c) Describe how the institution complies with the Institutional Requirements regarding “Resident Eligibility and Selection” and the development of appropriate criteria for the selection, evaluation, promotion and dismissal of fellows in accordance with the Program and Institutional Requirements. (IR II.A-B) d) Summarize how the institution complies with the ACGME Institutional Requirements regarding fellow support, benefits and conditions of employment to include the details of the fellow contract or agreement as outlined in the ACGME Institutional Requirements. (Do not append the fellow contract/agreement to the PIF but state when it is given to the fellows and applicants. Have a copy available for verification by the site visitor on the day of the survey with the various items required by the ACGME numbered according to the Institutional Requirements.) (IR II.C-D) e) Describe in detail the grievance (due process) procedure(s) that is available to fellows, including the composition of the grievance committee, and mechanisms for handling complaints and grievances related to actions which could result in dismissal, non-renewal of a fellow’s contract, or other actions that could significantly threaten a fellow’s intended career development. (IR II.D.4.c-d) Nuclear Radiology 3
  7. 7. C. FACULTY / RESOURCES 1. Program Director Information Name: Title: Address: City, State, Zip code: Telephone: FAX: Email: Date First Appointed as Program Director: Principal Activity Devoted to Fellow Education? Yes: No: Term of Program Director Appointment: Date first appointed as faculty member in the program: Number of hours per week Director spends in: Clinical Supervision: Administration: Research: Didactics/Teaching: Primary Specialty Board Certification: Most Recent Year: Subspecialty Board Certification: Most Recent Year: Number of years spent teaching in this subspecialty: a) Is the program director familiar with and does he/she oversee compliance with ACGME/RRC policies and procedures as outlined in the ACGME Manual of Policies and Procedures (found at http://www.acgme.org/acWebsite/about/ab_ACGMEPoliciesProcedures.pdf)? .....................................................................................................................( ) YES ( ) NO b) Using the form provided in section C.3. provide a one page CV for the program director. 2. Physician Faculty Roster Calculate the number of faculty required for your program, based on the requirement for one full time equivalent faculty member at the parent institution and integrated sites for each resident in the program. List alphabetically and by site the faculty counted by the program to meet this requirement. Using the form provided below, supply a one page CV for each faculty listed. Name (Position) Degree Based Mainly at Site # Primary and Secondary Specialties / Field Years as Faculty in Specialty Average Hours Per Week Devoted to Fellow Education Specialty / Field Board Certification (Y/N)† Recertification Date (PD) † Certification for the primary specialty refers to ABMS Board Certification. Certification for the subspecialty refers to ABMS sub-board certification. Nuclear Radiology 4
  8. 8. 3. Faculty Curriculum Vitae First Name: MI: Last Name: Present Position: Graduate Medical Education Program Name(s); include all residencies and fellowships: Certification and Re- Certification Information Current Licensure Data Specialty Certification Year Re-Certification Year State Date of Expiration (mm/yyyy) Academic Appointments - List the past ten years, beginning with your current position. Start Date (mm/yyyy) End Date (mm/yyyy) Description of Position(s) Present Concise Summary of Role in Program: Current Professional Activities / Committees: Selected Bibliography - Most representative Peer Reviewed Publications / Journal Articles from the last 5 years (limit of 10): Selected Review Articles, Chapters and/or Textbooks (Limit of 10 in the last 5 years): Participation in Local, Regional, and National Activities / Presentations - Abstracts (Limit of 10 in the last 5 years): If not ABMS board certified, explain equivalent qualifications for Review Committee consideration: 4. Non Physician Faculty Roster List alphabetically the non-physician faculty who provide required instruction or supervision of fellows in the program. Name (Position) Degree Based Primarily at Site # Subspecialty / Field Role In Program # of Years Teaching as Faculty in Subspecialty Nuclear Radiology 5
  9. 9. 5. Program Resources a) How will the program ensure that faculty (physician and nonphysician) have sufficient time to supervise and teach fellows? Include time spent in activities such as conferences, rounds, journal clubs, research, mentoring, teaching technical skills etc. if relevant. b) Briefly describe the educational and clinical resources available for fellow education. [The answer must include how specialty specific reference materials are accessible. It should also include resources provided by the program and the institution.] D. FELLOW APPOINTMENTS 1. Number of Positions (for the current academic year) Number of Requested Positions Number of Filled Positions* *Not applicable to new programs with no fellows on duty. Count part-time fellows as 0.5 FTE. If the number of filled positions exceeds the number of positions approved by the Review Committee, provide an explanation of this variance. 2. Actively Enrolled Fellows (if applicable) a) List alphabetically all fellows actively enrolled in this program as of August 31 of current academic year. Name Program Start Date Expected Completion Date Year in Program Years of Prior GME Specialty of Most Recent Prior GME Has completed an ACGME- accredited specialty program (Y/N) If no, explain b) Did you obtain documentation that each fellow has met the eligibility criteria? ( ) YES ( ) NO Nuclear Radiology 6
  10. 10. THE RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Suite 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org COMMON SUBSPECIALTY PROGRAM INFORMATION FORM PARTICIPATING SITES (PR.I.B.3.) Name of ACGME- accredited diagnostic radiology program with which the fellowship program is associated. (Not required for pediatric radiology). If the residency is not sponsored by the institution that sponsors the fellowship program, describe the affiliation between the fellowship and the residency. PROGRAM PERSONNEL AND RESOURCES Program Director (PR II.A.1.a.) What percentage of time does the program director spend in the subspecialty? ...........................( ) Other Program Personnel (PR II.C.1.) 1. Is there a program coordinator available to the program?....................................( ) YES ( ) NO If no, explain 2. Does the program coordinator have sufficient time and resources to support the administration and educational conduct of the program?...................................................................( ) YES ( ) NO If no, explain Resources (PR II.D.) Briefly describe the facilities and space, including study space, conference space, and access to computers, available for the education of fellow. Medical Information Access (PR II.E) Describe resources available for point of service teaching and learning utilized during read out session. The description should include the availability of electronic resources. FELLOW APPOINTMENTS 1. Explain the distinction between the diagnostic radiology residents and the fellows in terms of clinical activities and level of responsibility. Nuclear Radiology 7
  11. 11. 2. Will the fellow have responsibility for teaching residents? ...................................( ) YES ( ) NO If yes, describe. PATIENT CARE 1. Briefly describe how fellows provide consultation with referring physicians or services. (PR IV.A.2.a.(1)) 2. Do fellows have a clearly defined role in educating diagnostic residents, and if appropriate, medical students and other professional personnel in the care and management of patients? (PR IV.A.2.a.(2)) .................................................................................................( ) YES ( ) NO If no, explain 3. Provide examples of how fellows follow standards of care for practicing in a safe environment, attempt to reduce errors, and improve patient outcomes. (PR IV.A.2.a.(3)) Limit to 100 words • • • 4. Describe and provide examples of how fellows are educated in and apply low dose radiation techniques in both adults and children and how they become skilled in preventing and treating complications of contrast administration. (PR IV.A.2.a.(4) and IV.A.2.b.(2)) Limit to 200 words MEDICAL KNOWLEDGE (PR IV.A.2.B.(3)) Briefly describe how fellows develop skills in preparing and presenting educational material for medical students, graduate medical staff, and allied health personnel. Limit to 200 words INTERPERSONAL AND COMMUNICATION SKILLS (PR IV.A.2.D.(1)) List the methods used to evaluate the fellows written and oral communication skills. Limit to 200 words Nuclear Radiology 8
  12. 12. PROFESSIONALISM 1. Do fellows demonstrate compassion, integrity, and respect for others? (PR IV.A.2.e.(1)) ............................................................................................................................( ) YES ( ) NO 2. Do fellows demonstrate responsiveness to patient needs that supersedes self-interest? (PR IV.A.2.e.(2)...................................................................................................( ) YES ( ) NO 3. Do fellows demonstrate respect for patient privacy and autonomy? (PR IV.A.2.e.(3)) ............................................................................................................................( ) YES ( ) NO 4. Do fellows demonstrate accountability to patients, society and the profession? (PR IV.A.2.e.(4)) ............................................................................................................................( ) YES ( ) NO 5. Do fellows demonstrate sensitivity and responsiveness to a diverse patient population, including but not limited to diversity in gender, age, culture, race, religion, disabilities, and sexual orientation? (PR IV.A.2.e.(5))..................................................................................................( ) YES ( ) NO 6. Briefly describe how the program assesses fellow competence in the areas referenced in questions 1-5. 7. Describe how the program ensures that fellows demonstrate compliance with institutional and departmental policies (e.g., HIPAA, the JC, patient safety, infection control, etc). (PR IV.A.2.e.(6)) Limit to 200 words SYSTEMS-BASED PRACTICE 1. Describe how fellows work in interprofessional teams to enhance patient safety and improve patient care quality. (PR IV.A.2.f.(1)) Limit to 200 words 2. Provide specific examples of how fellows participate in identifying system errors and implementing potential systems solutions. (PR IV.A.2.f.(2)) Limit to 200 words CURRICULUM Conferences (PR IV.A.3.) 1. Do conferences include: a) Intradepartmental conferences (PR IV.A.3.a).................................................( ) YES ( ) NO If yes, how frequently does this occur? ................................( ) b) Departmental grand rounds (PR IV.A.3.b)......................................................( ) YES ( ) NO If yes, how frequently does this occur? ................................( ) Nuclear Radiology 9
  13. 13. c) At least one interdisciplinary conference per week (IV.A.3.c).........................( ) YES ( ) NO d) Peer review case conference and/or M&M conference (PR IV.A.3.d)............( ) YES ( ) NO If yes, how frequently does this occur?.................................( ) 2. Briefly describe the policy for fellow attendance and participation at local and national meetings. Indicate whether the program provides reimbursement. (PR IV.A.4) 3. Formal didactic sessions (PR IV.A.5) 1Enter the schedule of conferences and lectures for the most recent 12-month period. The specific title of lectures/sessions is requested. (PR IV.A.4-6) Reporting Period (Recent 12- month period): From: To: Topic Title Rotation Schedule (PR IV) Using the format provided in the sample below, provide a rotation schedule for the 12-month program. Insert additional rows as needed. SAMPLE Week/Month Rotation Title Site 4 weeks Emergency radiology 3 12 weeks CT/MRI 1 4 weeks Orthopedic elective 2 4 weeks MSK ultrasound 3 4 weeks Peds MSK 1 8 weeks MSK interventions 1 4 weeks PET/CT 4 4 weeks Research 2 8 weeks General MSK 1 Week/Month Rotation Title Site Nuclear Radiology 10
  14. 14. FELLOWS’ SCHOLARLY ACTIVITIES 1. Describe how fellows are instructed in the fundamentals of experimental design, performance, interpretation of results. (PR IV.B.1.) 2. List fellow scholarly projects for the current fellows and most recent graduates. Indicate whether the projects were submitted for publication or presented at departmental, institutional, local, regional, national or international meetings. (PR IV.B.2.) EVALUATION Fellow Formative Evaluation (PR V.A.1.b.(3).(a)) 1. Do fellow evaluations include at least a quarterly review?...................................( ) YES ( ) NO 2. Does the quarterly review include the following? a) review of the faculty’s evaluations of the fellow..............................................( ) YES ( ) NO b) review of the fellow’s procedure log...............................................................( ) YES ( ) NO c) documentation of compliance with institutional and department policies (e.g. HIPAA, the JC, patient safety, infection control, etc.)..............................................................( ) YES ( ) NO Explain any “no” responses. Faculty Evaluation (PR V.B.3.) 1. Do faculty evaluations include a written confidential evaluation by the fellows?...( ) YES ( ) NO 2. Do faculty receive annual feedback from these evaluations?...............................( ) YES ( ) NO Explain any “no” responses. Nuclear Radiology 11
  15. 15. 1111RESIDENCY REVIEW COMMITTEE FOR DIAGNOSTIC RADIOLOGY 515 N State, Ste 2000, Chicago, IL 60654 • (312) 755-5000 • www.acgme.org FOR CONTINUED ACCREDITATION - NUCLEAR RADIOLOGY INSTITUTIONAL DATA All information requested must be included for each site listed in the Common PIF. Reporting Period (Recent 12-month period): From: To: Site #1 Site #2 Site #3 Total beds in facility Adult Admissions Pediatric Admissions # cutoff age for pediatrics Newborn nursery admissions Neonatal intensive care unit admissions Total Admissions (enter on this line) Adult Outpatient visits Pediatric Outpatient (include neonates) Total Outpatients Visits *Note: The cutoff age used by each participating site for pediatric patients should be indicated. NARRATIVE DESCRIPTION 1. What are the principal objectives of the program? 2. Describe the organization of the teaching. 3. Explain the provision for graduated resident responsibility. 4. Explain the availability of attending coverage and provision for fellow supervision. 5. How does each of the participating sites contribute to the educational program? a) Describe the nature of fellow participation on rotations at the participating sites. Nuclear Radiology 12
  16. 16. 6. How does the program provide for graduated study, experience and responsibility in the following areas: a) nuclear radiologic diagnosis b) medical nuclear and diagnostic radiological physics c) radiobiology d) health physics and protection e) nuclear medicine instrumentation f) radiopharmaceutical chemistry and instrumentation g) clinical applications of nuclear radiology h) pathology 7. Describe how the fellows participate in the teaching conferences. a) How much responsibility do they have for their preparation and presentation? b) Is attendance/participation of fellows and faculty documented? ( ) YES ( ) NO 8. Describe briefly the research space and important special research facilities. a) List intramural research programs (not more than 5) being conducted by members of the Department, indicating those in which (if any) fellows participate. DO NOT SUBMIT COPIES OF PROTOCOLS, PAPERS OR GRANT APPLICATIONS. Nuclear Radiology 13
  17. 17. SPACE AND EQUIPMENT 1. Complete only for sites to which rotations total a minimum of 3 months Site #1 Site #2 Site #3 Nuclear Radiology (square feet)) Physics Radiological Research Other (specify) Allocation of Space: Number of examining rooms controlled by Nuclear Radiology (including any rooms used to perform patient examinations) Number of nuclear examining rooms not controlled by Radiology, but located in Nuclear Radiology space Number of Nuclear Radiology staff offices Number of conference rooms available to Nuclear Radiology for regular use Number of Nuclear Radiology resident offices/lounges 2. List number of units available to residents in each site. Include units in other departments, e.g., cardiology, GI and GU. Append copy of current equipment list. Nuclear Radiology Equipment Site #1 Site #2 Site #3 In Vivo Imaging/Counting Single or Multi Probe Counting Systems Tomographic Imaging Systems (specify) Cameras Stationary, standard or large field Mobile In Vitro Laboratory Other Nuclear Imaging Equipment (specify) 3. Are residents required to learn to operate, utilize or program any phase of computer utilization specifically part of nuclear units?...............................................................................( ) YES ( ) NO If yes, describe briefly: Nuclear Radiology 14
  18. 18. TEACHING FILE 1. Total number of cases in institutionally accumulated nuclear radiology file: ( ) 2. Does the department have a teaching file gathered from outside the site? ( ) YES ( ) NO 3. ACR file (list sections available and date of acquisition) Sections Available Date of Acquisition NUCLEAR RADIOLOGY PROCEDURES Provide the data requested below regarding the number of procedures performed at each site that participates in the program for the most recent 12 month period. Insert additional pages as needed. Procedure CPT code Site #1 Site #2 Site #3 Endocrine Thyroid Scan 78006, 78007, 78010 Thyroid Carcinoma_ Whole Body Scan 78018 Parathyroid Scan 78070 TOTAL GI Hepatobiliary Scan 78220, 78223 GI Bleed Scan 78278 Gastric Emptying Scan 78264 TOTAL Musculoskeletal Bone Scan 78300, 78305, 78306, 78315, 78320 Cardiovascular Myocardial Perfusion Gated SPECT 78464, 78465 Multigated Cardiac Blood Pool Scan 78472, 78473 TOTAL Respiratory System Lung VQ Scan 78585, 78588 CNS Brain SPECT 78607 Brain PET 78608, 78609 CSF study 78630, 78650 Nuclear Radiology 15
  19. 19. TOTAL Genitourinary Renal Scan 78707, 78708, 78709 Tumor and Infection Tumor localization (planar/Spect) 78800, 78801, 78802, 78803 Tumor PET 78811, 78812, 78813 Tumor PET/CT 78814, 78815, 78816 Inflammatory/ Infection localization 78805, 78806, 78807 Lymphoscintigraphy 78195 TOTAL Radiopharmaceutical Therapy Oral 79005 Intravenous 79101 Intra-arterial 79445 TOTAL Nuclear Radiology 16

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