DHS 124.17(2)(a)2. 2. The pathologist shall participate in staff, departmental and clinicopathologic conferences.
DHS 124.17(2)(a)3. 3. The pathologist shall be responsible for the qualifications of staff.
DHS 124.17(2)(a)4. 4. An autopsy may be performed only by a pathologist or an otherwise qualified physician.
DHS 124.17(2)(b) (b) Tissue examination.
DHS 124.17(2)(b)1.1. The medical staff and a pathologist shall determine which tissue specimens require macroscopic examination and which require both macroscopic and microscopic examinations.
DHS 124.17(2)(b)2. 2. 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.
DHS 124.17(2)(b)3. 3. 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.
DHS 124.17(2)(b)4. 4. 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 (CLIA).
DHS 124.17(2)(c) (c) Records.
DHS 124.17(2)(c)1.1. All reports of macroscopic and microscopic tissue examinations shall be authenticated by the pathologist or otherwise qualified physician.
DHS 124.17(2)(c)2. 2. 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.
DHS 124.17(2)(c)3. 3. The autopsy report shall be distributed to the attending physician and shall be made a part of the patient's record.
DHS 124.17(2)(c)4. 4. Duplicate records of the examination reports shall be kept in the laboratory and maintained in a manner which permits ready identification and accessibility.
DHS 124.17(3) (3)Blood bank services.
DHS 124.17(3)(a) (a) Access. Facilities for procurement, safekeeping and transfusion of blood and blood products shall be provided or made readily available, as follows:
DHS 124.17(3)(a)1. 1. The hospital shall maintain proper blood and blood product storage facilities under adequate control and supervision of the pathologist or other authorized physician;
DHS 124.17(3)(a)2. 2. 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;
DHS 124.17(3)(a)3. 3. 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
DHS 124.17(3)(a)4. 4. 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.
DHS 124.17(3)(b) (b) Safety precautions.
DHS 124.17(3)(b)1.1. Blood storage facilities in the hospital shall have an adequate refrigeration alarm system, which shall be regularly inspected.
DHS 124.17(3)(b)2. 2. Blood and blood products not used by their expiration dates shall be disposed of promptly.
DHS 124.17(3)(c) (c) Records. 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.
DHS 124.17(3)(d) (d) Review committee.
DHS 124.17(3)(d)1.1. 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.
DHS 124.17(3)(d)2. 2. 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.
DHS 124.17(4) (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 (CLIA).
DHS 124.17 History 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 DHS 124.18Radiological services.
DHS 124.18(1)(1)Diagnostic x-ray services.
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.
DHS 124.18(1)(b) (b) Location. 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.
DHS 124.18(1)(c) (c) Safety.
DHS 124.18(1)(c)1.1. The radiological service shall be free of hazards for patients and personnel.
DHS 124.18(1)(c)2. 2. Proper safety precautions shall be maintained against fire and explosion hazards, electrical hazards and radiation hazards.
DHS 124.18(1)(c)3. 3. 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.
DHS 124.18(1)(c)4. 4. Radiation workers shall be monitored in accordance with ch. DHS 157.
DHS 124.18(1)(c)5. 5. Attention shall be paid to modern safety design and proper operating procedures under ss. DHS 157.75 to 157.76 for the use of fluoroscopes. Records shall be maintained of the output of all fluoroscopes.
DHS 124.18(1)(c)6. 6. 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.
DHS 124.18(1)(d) (d) Personnel.
DHS 124.18(1)(d)1.1. A sufficient number of personnel capable of supervising and carrying out the radiological services shall be provided.
DHS 124.18(1)(d)2. 2. The interpretation of radiological examinations shall be made by physicians qualified in the field.
DHS 124.18(1)(d)3. 3. 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.
DHS 124.18(1)(d)4. 4. A technologist shall be on duty or on call at all times.
DHS 124.18(1)(d)5. 5. 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.
DHS 124.18(1)(e) (e) Records.
DHS 124.18(1)(e)1.1. Authenticated radiological reports shall be filed in the patient's medical record.
DHS 124.18(1)(e)2. 2. 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.
DHS 124.18(1)(e)3. 3. 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.
DHS 124.18(1)(e)4. 4. Copies of reports, printouts, films, scans and other image records shall be retained for at least 5 years.
DHS 124.18(2) (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 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.
DHS 124.19 DHS 124.19Nuclear medicine services.
DHS 124.19(1)(1)Nuclear medicine service.
DHS 124.19(1)(a) (a) Requirement. 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.
DHS 124.19(1)(b) (b) Organization and staffing.
DHS 124.19(1)(b)1.1. The organization of the nuclear medicine service shall be appropriate for the scope and complexity of the services offered.
DHS 124.19(1)(b)2. 2. There shall be a physician director who is qualified in nuclear medicine to be responsible for the nuclear medicine service.
DHS 124.19(1)(b)3.a.a. 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.
DHS 124.19(1)(b)3.b. b. Only persons approved by the hospital may participate in the preparation of radiopharmaceuticals.
DHS 124.19(1)(b)3.c. c. All persons who administer radioisotopes shall be approved by the medical staff and by the hospital's administrative staff.
DHS 124.19(1)(b)4. 4. The number and types of personnel assigned to nuclear medicine shall be adequate to provide the needed services.
DHS 124.19(1)(c) (c) Location. Nuclear medicine services shall be provided in an area of the hospital that is adequately shielded.
DHS 124.19(1)(d) (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.
DHS 124.19(1)(e) (e) Equipment and supplies.
DHS 124.19(1)(e)1.1. Equipment and supplies shall be appropriate for the types of nuclear medicine services offered and shall be maintained for safe and efficient performance.
DHS 124.19(1)(e)2. 2. 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.
DHS 124.19(1)(f) (f) Records.
DHS 124.19(1)(f)1.1. 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.
DHS 124.19(1)(f)2. 2. Records shall note the amount of radiopharmaceuticals administered, the identity of the recipient, the supplier and lot number and the date of therapy.
DHS 124.19(1)(f)3. 3. 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.
DHS 124.19(1)(f)4. 4. 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.
DHS 124.19(2) (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 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.
DHS 124.20 DHS 124.20Clinical services.
DHS 124.20(1)(1)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.
DHS 124.20(2) (2)Surgery.
DHS 124.20(2)(a) (a) Policies.
DHS 124.20(2)(a)1.1. 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.
DHS 124.20(2)(a)2. 2. 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.
DHS 124.20(2)(a)3. 3. 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.
DHS 124.20(2)(a)4. 4. 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.
DHS 124.20(2)(a)5. 5. 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.
DHS 124.20(2)(a)6. 6. Rules and policies relating to the operating rooms shall be available and posted in appropriate locations inside and outside the operating rooms.
DHS 124.20(2)(b) (b) Supervision. The operating rooms shall be supervised by a registered nurse who is qualified by training and experience to supervise the operating rooms.
DHS 124.20(2)(c) (c) Environment.
DHS 124.20(2)(c)1.1. The following equipment shall be available to the operating suites: a call-in system, resuscitator, defibrillator, aspirator, thoracotomy set and tracheotomy set.
Published under s. 35.93, Stats. Updated on the first day of each month. Entire code is always current. The Register date on each page is the date the chapter was last published.