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Nuclear Medicine

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Nuclear Medicine Nuclear Medicine Document Transcript

  • Initial Assessment – Nuclear Medicine Legal Operating Name             Address Street City, Province Postal                   Medical Director             Telephone: (     )     -      Email:             Fax: (     )     -      Facility Manager             Telephone: (     )     -      Email:       Fax: (     )     -      Chief Technologist             Telephone: (     )     -      Email:       Fax: (     )     -      Number of rooms:      Personnel Days and Hours of Number of Technologists:       List of physicians credentialed by the DAP to perform Operation:       nuclear medicine services:             Are all examinations interpreted on-site? Yes No If no, provide the following information: Reporting facility name:       Name of qualified interpreting physician at reporting facility:       How are images delivered to other facilities for reporting? Digital Delivery (Also, complete and return the PACS Initial Assessment.) Other, explain:       Indicate when an interpreting physician is present at the nuclear medicine facility.       Are examinations received from other facilities for interpretation? Yes No (If yes, and images are digitally transmitted, also complete and return the PACS Initial Assessment.) Comment       Page 1 of 8 July 2007
  • For all questions below, Electronically check or manually indicate the appropriate responses. Please provide narrative response, where appropriate. Human Resources DAP Use Only 1.1 Is orientation provided to all new staff that includes initial Yes No training and information about the organization, facility and Comment:       their position? Yes No, explain:       1.2 Are all technologists currently registered with their Yes No professional association? (Please provide C.V.’s) Comment:       Yes No, explain:       1.3 Are all physicians who interpret examinations licensed as Yes No recognized by the College of Physicians and Surgeons of Comment:       BC? (Please provide C.V.’s) Yes No, explain:       1.4 Are any examinations performed by staff members who are Yes No not registered? Comment:       Yes No, explain:             1.5 Diagnostic Image quality is verified by the Medical Director or Comment:       designated physician at the facility. Please include the name of the physician who reviews images to confirm diagnostic quality. Name:       Page 2 of 8 July 2007
  • Quality Assurance DAP Use Only 2.1 Are there staff member(s) in the nuclear medicine facility who Yes No are responsible for monitoring quality control and assessing Comment:       relative changes in system performance? Yes No, explain:       2.2 Is there a policy for regular equipment quality control testing? Yes No Yes No. Comment:       Please provide descriptive narrative of QC program:       2.3 Is there a policy for regular radiopharmaceutical quality Yes No control testing? Comment:       Please provide descriptive narrative of QC program:       2.4 Is there a policy for retention of QC test results? Yes No Yes No, explain:       Comment:       Page 3 of 8 July 2007
  • Equipment DAP Use Only 3.1 List all Nuclear Medicine Cameras: (Manufacturer, Model, Comment:       and Year) 1.       2.       3.       4.       3.2 List Uptake probes: Comment:       1.       2.       3.       4.       3.3 List well counters/ dose calibrators/ multi-channel analyzers: 1.       Comment:       2.       3.       4.       3.4 Is ancillary equipment adequate to meet the needs of Yes No examinations performed? Comment:       Yes No, explain:       3.5 Did cameras undergo comprehensive acceptance testing on Yes No installation? Comment:       Yes No, explain:       3.6 Is there a policy to perform routine preventative maintenance Yes No on the equipment? Comment:       Yes No, explain:       3.7 Is there a policy to retain routine maintenance checks and Yes No repair records? Comment:       Yes No, explain:       Page 4 of 8 July 2007
  • Safety DAP Use Only 4.1 Is there signage in all patient areas that is clearly visible, Yes No alerting women who may be pregnant or breast feeding to Comment:       notify the technologist? Yes No, explain:       4.2 Are suction and oxygen readily available? Yes No Yes No, explain:       Comment:       4.3 Is there an emergency crash cart readily available? Yes No Yes No, explain:       Comment:       4.4 Are there policies in place for appropriate transportation of Yes No biohazardous and radioactive materials? Comment:       Yes No, explain:       4.5 Does the nuclear medicine facility have a radiation safety Yes No officer or designated individual responsible for overseeing Comment:       radiation protection? Yes No, explain:       Page 5 of 8 July 2007
  • Storage of Data and Images DAP Use Only Comment:       5.1 What media device is used for long-term storage?      5.2 Can all electronically stored images be sent to film/ CDROM Yes No or other devices in a timely fashion for off-site review? Comment:       Yes No, explain:       5.3 Do you backup image and database data daily? Yes No Yes No, explain:       Comment:       5.4 Do you have a protocol to manage and report data integrity Yes No errors? For example, is there a protocol to address when the Comment:       incorrect name is displayed on the image? Yes No, explain:       5.5 Do you have Picture Archive and Communication Systems Yes No (PACS) at your facility? Comment:       Yes No, explain:       If yes: 5.5.1 Do you have a designated individual responsible for Yes No quality control and data integrity? Comment:       Yes No, explain:       5.5.2 If images are sent to PACS, do you have a downtime Yes No protocol? Comment:       Yes No, explain:       Page 6 of 8 July 2007
  • Safety-Appropriate Physical Environment DAP Use Only 6.1 Does the design and layout of the facility space meet laws, Yes No regulations and codes? (i.e. building codes, fire codes etc.) Comment:       Yes No, explain:       6.2 Is the location of the facility accessible and appropriate for the Yes No patient population it serves?       Comment:       6.3 Does the physical environment of the facility meet patient Yes No needs? Comment:       Yes No, explain:       6.4 Does the design and layout of the space allow for the patient Yes No privacy and confidentiality? Comment:       Yes No, explain:       6.5 Does the physical environment of the facility meet the needs Yes No of staff and support efficient workflow? Comment:       Yes No, explain:       6.6 Is appropriate space available for the following: Yes No Comment:       .a “Hot” and “Cold” patient waiting area Yes No .b “Hot” and “Cold” patient washrooms Yes No .c Radiopharmacy lab Yes No .d Cell labeling Yes No .e Injection area Yes No .f Cardiac ECG lab, where appropriate Yes No Page 7 of 8 July 2007
  • Name of the person completing this form:       Medical Director Signature This Initial Assessment must be signed-off by the Senior Medical Leader/Director. Please complete, print, sign and fax this page to the Diagnostic Accreditation Program. 604-739-6659. All previous sections of the document may be electronically returned. Facility Name:       Imaging Service Name:       I have reviewed the information in this document and acknowledge that it is accurate and correct. ______________________________________________ Senior Medical Leader/Director (printed name) ______________________________________________ Signature of Senior Medical Leader/Director ___________________________ Date Comments:       Page 8 of 8 July 2007