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Nuclear Medicine

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  • 1. 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 Operation:             Number of Technologists:       List of physicians credentialed by the DAP to perform 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:Name of qualified interpreting physician at reporting facility:            How are images delivered to other facilities for reporting?How are images delivered to other facilities for reporting? Digital Delivery (Also, complete and return the PACS Initial Assessment.)Digital Delivery (Also, complete and return the PACS Initial Assessment.) Other, explain: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
  • 2. 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 training and information about the organization, facility and their position? Yes No, explain:       Yes No Comment:       1.2 Are all technologists currently registered with their professional association? (Please provide C.V.’s) Yes No, explain:       Yes No Comment:       1.3 Are all physicians who interpret examinations licensed as recognized by the College of Physicians and Surgeons of BC? (Please provide C.V.’s) Yes No, explain:       Yes No Comment:       1.4 Are any examinations performed by staff members who are not registered? Yes No, explain:             Yes No Comment:       1.5 Diagnostic Image quality is verified by the Medical Director or designated physician at the facility. Please include the name of the physician who reviews images to confirm diagnostic quality. Name:       Comment:       Page 2 of 8 July 2007
  • 3. Quality Assurance DAP Use Only 2.1 Are there staff member(s) in the nuclear medicine facility who are responsible for monitoring quality control and assessing relative changes in system performance? Yes No, explain:       Yes No Comment:       2.2 Is there a policy for regular equipment quality control testing? Yes No. Please provide descriptive narrative of QC program:       Yes No Comment:       2.3 Is there a policy for regular radiopharmaceutical quality control testing? Please provide descriptive narrative of QC program:       Yes No Comment:       2.4 Is there a policy for retention of QC test results? Yes No, explain:       Yes No Comment:       Page 3 of 8 July 2007
  • 4. Equipment DAP Use Only 3.1 List all Nuclear Medicine Cameras: (Manufacturer, Model, and Year) 1.       2.       3.       4.       Comment:       3.2 List Uptake probes: 1.       2.       3.       4.       Comment:       3.3 List well counters/ dose calibrators/ multi-channel analyzers: 1.       2.       3.       4.       Comment:       3.4 Is ancillary equipment adequate to meet the needs of examinations performed? Yes No, explain:       Yes No Comment:       3.5 Did cameras undergo comprehensive acceptance testing on installation? Yes No, explain:       Yes No Comment:       3.6 Is there a policy to perform routine preventative maintenance on the equipment? Yes No, explain:       Yes No Comment:       3.7 Is there a policy to retain routine maintenance checks and repair records? Yes No, explain:       Yes No Comment:       Page 4 of 8 July 2007
  • 5. Safety DAP Use Only 4.1 Is there signage in all patient areas that is clearly visible, alerting women who may be pregnant or breast feeding to notify the technologist? Yes No, explain:       Yes No Comment:       4.2 Are suction and oxygen readily available? Yes No, explain:       Yes No Comment:       4.3 Is there an emergency crash cart readily available? Yes No, explain:       Yes No Comment:       4.4 Are there policies in place for appropriate transportation of biohazardous and radioactive materials? Yes No, explain:       Yes No Comment:       4.5 Does the nuclear medicine facility have a radiation safety officer or designated individual responsible for overseeing radiation protection? Yes No, explain:       Yes No Comment:       Page 5 of 8 July 2007
  • 6. Storage of Data and Images DAP Use Only 5.1 What media device is used for long-term storage?      Comment:       5.2 Can all electronically stored images be sent to film/ CDROM or other devices in a timely fashion for off-site review? Yes No, explain:       Yes No Comment:       5.3 Do you backup image and database data daily? Yes No, explain:       Yes No Comment:       5.4 Do you have a protocol to manage and report data integrity errors? For example, is there a protocol to address when the incorrect name is displayed on the image? Yes No, explain:       Yes No Comment:       5.5 Do you have Picture Archive and Communication Systems (PACS) at your facility? Yes No, explain:       If yes: Yes No Comment:       5.5.1 Do you have a designated individual responsible for quality control and data integrity? Yes No, explain:       Yes No Comment:       5.5.2 If images are sent to PACS, do you have a downtime protocol? Yes No, explain:       Yes No Comment:       Page 6 of 8 July 2007
  • 7. Safety-Appropriate Physical Environment DAP Use Only 6.1 Does the design and layout of the facility space meet laws, regulations and codes? (i.e. building codes, fire codes etc.) Yes No, explain:       Yes No Comment:       6.2 Is the location of the facility accessible and appropriate for the patient population it serves?       Yes No Comment:       6.3 Does the physical environment of the facility meet patient needs? Yes No, explain:       Yes No Comment:       6.4 Does the design and layout of the space allow for the patient privacy and confidentiality? Yes No, explain:       Yes No Comment:       6.5 Does the physical environment of the facility meet the needs of staff and support efficient workflow? Yes No, explain:       Yes No Comment:       6.6 Is appropriate space available for the following: .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 Yes No Comment:       Page 7 of 8 July 2007
  • 8. 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

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