The pathologist shall participate in staff, departmental and clinicopathologic conferences.
The pathologist shall be responsible for the qualifications of staff.
An autopsy may be performed only by a pathologist or an otherwise qualified physician.
The medical staff and a pathologist shall determine which tissue specimens require macroscopic examination and which require both macroscopic and microscopic examinations.
The hospital shall maintain an ongoing file of tissue slides and blocks. Nothing in this section shall be interpreted as prohibiting the use of outside laboratory facilities for storage and maintenance of records, slides and blocks.
If the hospital does not have a pathologist or otherwise qualified physician, there shall be an established plan for sending all tissues requiring examination to a pathologist outside the hospital.
A log of all tissues sent outside the hospital for examination shall be maintained. Arrangements for tissue examinations done outside the hospital shall be made with a laboratory approved under approved under 42 CFR 493
All reports of macroscopic and microscopic tissue examinations shall be authenticated by the pathologist or otherwise qualified physician.
Provisions shall be made for the prompt filing of examination results in the patient's medical record and for notification of the physician or dentist who requested the examination.
The autopsy report shall be distributed to the attending physician and shall be made a part of the patient's record.
Duplicate records of the examination reports shall be kept in the laboratory and maintained in a manner which permits ready identification and accessibility.
Facilities for procurement, safekeeping and transfusion of blood and blood products shall be provided or made readily available, as follows:
The hospital shall maintain proper blood and blood product storage facilities under adequate control and supervision of the pathologist or other authorized physician;
For emergency situations the hospital shall maintain at least a minimum blood supply in the hospital at all times and have a written plan for acquiring blood quickly, as needed, from an outside source;
Where the hospital depends on an outside blood bank, there shall be an agreement between the hospital and the outside blood bank to govern the procurement, transfer and availability of blood and blood products. That agreement shall be reviewed and approved by the medical staff, chief executive officer and governing body; and
There shall be provision for prompt blood typing and cross-matching, either by the hospital or by arrangement with others on a continuing basis, and under the supervision of a physician.
Blood storage facilities in the hospital shall have an adequate refrigeration alarm system, which shall be regularly inspected.
Blood and blood products not used by their expiration dates shall be disposed of promptly.
A record shall be kept on file in the laboratory and in the patient's medical record to indicate the receipt and disposition of all blood and blood products provided to the patient in the hospital.
A committee of the medical staff shall review all transfusions of blood or blood derivatives and make recommendations to the medical staff concerning policies to govern practice.
The review committee shall investigate all transfusion reactions occurring in the hospital and shall make recommendations to the medical staff for improvements in transfusion procedures.
(4) Proficiency testing.
The hospital laboratory shall participate in proficiency testing programs that are offered or approved in those specialties for which the laboratory offers services, as specified in 42 CFR 493
DHS 124.17 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88; corrections in (1) (b), (c), (2) (b) and (4) made under s. 13.93 (2m) (b) 7., Stats., Register, January, 1999, No. 517
DHS 124.17 Note
Note: See the table of Appellate Court Citations for Wisconsin appellate cases citing s. HSS 124.17.
DHS 124.18(1)(a)(a) Requirement.
The hospital shall make diagnostic x-ray services available. These services shall meet professionally approved standards for safety and the qualifications of personnel in addition to the requirements set out in this subsection.
The hospital shall have diagnostic x-ray facilities available in the hospital building proper or in an adjacent clinic or medical facility that is readily accessible to the hospital's patients, physicians and staff.
The radiological service shall be free of hazards for patients and personnel.
Proper safety precautions shall be maintained against fire and explosion hazards, electrical hazards and radiation hazards.
Hospital x-ray facilities shall be inspected by a qualified radiation physicist or by a department radiation consultant at least once every 2 years for compliance with ch. DHS 157
. Hazards identified by inspections shall be properly and promptly corrected.
Attention shall be paid to modern safety design and proper operating procedures under ss. DHS 157.75
for the use of fluoroscopes. Records shall be maintained of the output of all fluoroscopes.
Policies based on medical staff recommendations shall be established for administration of the application and removal of radium element, its disintegration products and other radioactive isotopes.
A sufficient number of personnel capable of supervising and carrying out the radiological services shall be provided.
The interpretation of radiological examinations shall be made by physicians qualified in the field.
The hospital shall have a board-certified radiologist, full-time, part-time or on a consulting basis, who is qualified to direct the service and to interpret films that require specialized knowledge for accurate reading.
Only personnel designated as qualified by the radiologist or by an appropriately constituted committee of the medical staff may use the x-ray apparatus, and only similarly designated personnel may apply and remove the radium element, its disintegration products and radioactive isotopes. Fluoroscopic equipment may be operated only by properly trained persons authorized by the medical director of the radiological service.
Authenticated radiological reports shall be filed in the patient's medical record.
A written order for an x-ray examination by the attending physician or another individual authorized by the medical staff to order an x-ray examination shall contain a concise statement of the reason for the examination.
Interpretations of x-rays shall be written or dictated and shall be signed by a qualified physician or another individual authorized by the medical staff to interpret x-rays.
Copies of reports, printouts, films, scans and other image records shall be retained for at least 5 years.
(2) Therapeutic x-ray services.
If therapeutic x-ray services are provided, they shall meet professionally approved standards for safety and for qualifications of personnel. The physician in charge shall be appropriately qualified. Only a physician qualified by training and experience may prescribe radiotherapy treatments.
DHS 124.18 History
Cr. Register, January, 1988, No. 365
, eff. 2-1-88; corrections in (1) (c) 3. to 5. made under s. 13.93 (2m) (b) 7., Stats., Register September 2003 No. 573
; corrections in (1) (c) 3. to 5. made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637
If a hospital provides nuclear medicine services, the services shall meet the needs of the hospital's patients in accordance with acceptable standards of professional practice.
The organization of the nuclear medicine service shall be appropriate for the scope and complexity of the services offered.
There shall be a physician director who is qualified in nuclear medicine to be responsible for the nuclear medicine service.
The qualifications, education, training, functions and legal responsibilities of nuclear medicine personnel shall be specified by the director of the service and approved by the medical staff and chief executive officer.
Only persons approved by the hospital may participate in the preparation of radiopharmaceuticals.
All persons who administer radioisotopes shall be approved by the medical staff and by the hospital's administrative staff.
The number and types of personnel assigned to nuclear medicine shall be adequate to provide the needed services.
Nuclear medicine services shall be provided in an area of the hospital that is adequately shielded.
(d) Radioactive materials.
Radioactive materials shall be prepared, labeled, used, transported, stored and disposed of in accordance with applicable regulations of the U.S. nuclear regulatory commission and ch. DHS 157
Equipment and supplies shall be appropriate for the types of nuclear medicine services offered and shall be maintained for safe and efficient performance.
All equipment shall be maintained in safe operating condition and shall be inspected, tested and calibrated at least annually by a radiation or health physicist.
Authenticated and dated reports of nuclear medicine interpretations, consultations and therapy shall be made part of the patient's medical record and copies shall be retained by the service.
Records shall note the amount of radiopharmaceuticals administered, the identity of the recipient, the supplier and lot number and the date of therapy.
The hospital shall provide for monitoring the staff's exposure to radiation. The cumulative radiation exposure for each staff member shall be recorded in the service's records at least monthly.
Records of the receipt and disposition of radiopharmaceuticals shall be maintained. Documentation of instrument performance and records of inspection shall be retained in the service.
(2) Mobile nuclear medicine services.
The use of mobile nuclear medicine services by a facility to meet the diagnostic needs of its patients shall be subject to approval of the medical staff and the chief executive officer. The services offered by the mobile nuclear medicine unit shall comply with all applicable rules of this section.
DHS 124.19 History
Cr. Register, January, 1988, No. 385
, eff. 2-1-88; correction in (1) (d) made under s. 13.93 (2m) (b) 7., Stats., Register September 2003 No. 573
; correction in (1) (d) made under s. 13.92 (4) (b) 7., Stats., Register January 2009 No. 637
Service policies and procedures.
Hospitals which have surgery, anesthesia, dental or maternity services shall have effective policies and procedures, in addition to those set forth under s. DHS 124.12 (9)
, relating to the staffing and functions of each service in order to protect the health and safety of the patients.
Surgical privileges shall be delineated for each member of the medical staff performing surgery in accordance with the individual's competencies and shall be on file with the operating room supervisor.
The surgical service shall have a written policy to ensure that the patient will be safe if a member of the surgical team becomes incapacitated.
The surgical service shall have the ability to retrieve information needed for infection surveillance, identification of personnel who assisted at operative procedures and the compiling of needed statistics.
There shall be adequate provisions for immediate postoperative care. A patient may be directly discharged from post-anesthetic recovery status only by an anesthesiologist, another qualified physician or a registered nurse anesthetist.
All infections of clean surgical cases shall be recorded and reported to the hospital administrative staff and the infection control committee. There shall be a procedure for investigating the causes of infection.
Rules and policies relating to the operating rooms shall be available and posted in appropriate locations inside and outside the operating rooms.
The operating rooms shall be supervised by a registered nurse who is qualified by training and experience to supervise the operating rooms.
The following equipment shall be available to the operating suites: a call-in system, resuscitator, defibrillator, aspirator, thoracotomy set and tracheotomy set.