DHS 157.73(22) (22)Records and retention periods. A licensee shall maintain all the following records at the irradiator for the periods specified:
DHS 157.73(22)(a) (a) A copy of the license, the license conditions, documents incorporated into the license by reference and amendments thereto until superseded by new documents or until the department terminates the license for documents not superseded.
DHS 157.73(22)(b) (b) Records of each individual's training, tests and safety reviews provided to meet the requirements of sub. (12) (a) to (d), (f) and (g) until 3 years after the person terminates work.
DHS 157.73(22)(c) (c) Records of the annual evaluations of the safety performance of irradiator operators required by sub. (12) (e) for 3 years after the evaluation.
DHS 157.73(22)(d) (d) A copy of the current operating and emergency procedures required by sub. (13) until superseded or until the department terminates the license. Records of the radiation safety officer's review and approval of changes in procedures as required by sub. (13) (c) 3. shall be retained for 3 years from the date of the change.
DHS 157.73(22)(e) (e) Dosimetery results required by sub. (14) (a) and (b) until the department terminates the license.
DHS 157.73(22)(f) (f) Records of radiation surveys required by sub. (15) for 3 years from the survey date.
DHS 157.73(22)(g) (g) Records of radiation survey meter calibrations required by sub. (15) and pool water conductivity meter calibrations required by sub. (18) (b) until 3 years from the calibration date.
DHS 157.73(22)(h) (h) Records of the results of leak tests required by sub. (16) (a) and the results of contamination checks required by sub. (16) (b) for 3 years from the date of each test.
DHS 157.73(22)(i) (i) Records of inspection and maintenance checks required by sub. (17) for 3 years.
DHS 157.73(22)(j) (j) Records of major malfunctions, significant defects, operating difficulties or irregularities, and major operating problems that involve required radiation safety equipment for 3 years after repairs are completed.
DHS 157.73(22)(k) (k) Records of the receipt, transfer and disposal of all licensed sealed sources as required by s. DHS 157.13 (15) and (18).
DHS 157.73(22)(L) (L) Records on the design checks required by sub. (10) and the construction control checks as required by sub. (11) until the license is terminated. The records shall be signed and dated. The title or qualification of the person signing shall be included.
DHS 157.73(22)(m) (m) Records related to decommissioning of the irradiator as required by s. DHS 157.15 (7).
DHS 157.73(23) (23)Reports.
DHS 157.73(23)(a)(a) In addition to the reporting requirements in other parts of this chapter, a licensee shall report to the department all of the following events:
DHS 157.73(23)(a)1. 1. Source stuck in an unshielded position.
DHS 157.73(23)(a)2. 2. Any fire or explosion in a radiation room.
DHS 157.73(23)(a)3. 3. Damage to the source racks.
DHS 157.73(23)(a)4. 4. Failure of the cable or drive mechanism used to move the source racks.
DHS 157.73(23)(a)5. 5. Inoperability of the access control system.
DHS 157.73(23)(a)6. 6. Detection of radiation source by the product exit monitor.
DHS 157.73(23)(a)7. 7. Detection of radioactive contamination attributable to licensed radioactive material.
DHS 157.73(23)(a)8. 8. Structural damage to the pool liner or walls.
DHS 157.73(23)(a)9. 9. Water loss or leakage from the source storage pool, greater than the irradiator pool design parameters submitted by the licensee or applicant.
DHS 157.73(23)(a)10. 10. Pool water conductivity exceeding 100 microsiemens per centimeter.
DHS 157.73(23)(b) (b) For any event in par. (a), a licensee shall provide a telephone report within 24 hours that meets the requirements of s. DHS 157.32 (2) and a written report within 30 days that meets the requirements of s. DHS 157.32 (3).
DHS 157.73 History History: CR 01-108: cr. Register July 2002 No. 559, eff. — see Note at the start of the chapter; CR 06-021: am. (15) (c), (22) (k) and (m) Register October 2006 No. 610, eff. 11-1-06.
subch. VIII of ch. DHS 157 Subchapter VIII — X-ray Device Requirements
DHS 157.74 DHS 157.74 Administrative requirements.
DHS 157.74(1) (1) General. The registrant shall be responsible for directing the operation of the x-ray systems under their administrative control. The registrant or the registrant's agent shall ensure the requirements of this section are met. An x-ray system shall meet the provisions of this subchapter to be operated for diagnostic or screening purposes. All images, hard copy or electronic, shall be interpreted by a licensed practitioner for the patient record.
DHS 157.74(2) (2)Radiation safety requirements.
DHS 157.74(2)(a)(a) Each individual who operates x-ray equipment shall be instructed in the safe operating procedures for each specific device and be competent in the safe use of the equipment as determined by the registrant.
DHS 157.74(2)(b) (b) A chart shall be available near the control panel of a diagnostic x-ray system that specifies, for all examinations performed with that system, all of the following information:
DHS 157.74(2)(b)1. 1. Patient's body part to be examined and anatomical size, body part thickness or, for pediatrics, age versus technique factors to be utilized.
DHS 157.74(2)(b)2. 2. Type and size of the film or film-screen combination to be used.
DHS 157.74(2)(b)3. 3. Type and focal distance of the grid to be used, if any.
DHS 157.74(2)(b)4. 4. Except for dental intra-oral radiography, source to image receptor distance to be used.
DHS 157.74(2)(b)5. 5. Type and location of placement of patient shielding to be used.
DHS 157.74 Note Note: This chart may be electronic in the form of pre-programmed controls.
DHS 157.74(2)(c) (c) The registrant of a facility shall create and make available to x-ray operators written safety procedures, including patient holding procedures and any restrictions of the operating technique required for the safe operation of the particular x-ray system. The operator shall be able to demonstrate familiarity with these procedures.
DHS 157.74(2)(d) (d) Only the staff, ancillary personnel or other persons required for the medical procedure or training may be in the room during the radiographic exposure. Other than the patient, the following applies to all persons in the room:
DHS 157.74(2)(d)1. 1. All persons shall be positioned such that no part of the body will be struck by the useful beam unless protected by not less than 0.5 millimeter lead equivalent material. If the hands must be in the beam and unprotected, a ring badge on the hand in the beam shall be worn unless contraindicated by the clinical procedure.
DHS 157.74(2)(d)2. 2. All persons, including any patients who cannot be removed from the room, shall be protected from the direct scatter radiation by whole body protective barriers of not less than 0.25 millimeter lead equivalent material or shall be so positioned that all parts of the person's body are at least 2 meters from all of the following:
DHS 157.74(2)(d)2.a. a. The tube head.
DHS 157.74(2)(d)2.b. b. The direct beam.
DHS 157.74(2)(d)2.c. c. The nearest part of the examined patient's body being struck by the useful beam.
DHS 157.74(2)(d)3. 3. Operators of c-arm configuration units which do not operate at a tube current in excess of 0.2 mA are exempt from the requirement to wear a leaded apron, provided the operator wears a personnel dosimeter as required under s. DHS 157.25 (2).
DHS 157.74(2)(e) (e) Gonad shielding of not less than 0.5 millimeter lead equivalent material shall be used for human patients who have not passed the reproductive age during radiographic procedures in which the gonads are in the useful beam, except for cases in which the shielding would interfere with the diagnostic procedure or for computed radiographic examinations.
DHS 157.74(2)(f) (f) Persons may not be exposed to the useful beam except for healing arts purposes and unless such exposure has been authorized by a licensed practitioner of the healing arts. Deliberate exposure for any of the following purposes is prohibited:
DHS 157.74(2)(f)1. 1. Exposure of a person for training, demonstration or other non-healing arts purpose.
DHS 157.74(2)(f)2. 2. Exposure of a person for healing arts screening, except as authorized by the department.
DHS 157.74 Note Note: The procedure for requesting permission to conduct screening x-ray examination is in Appendix M.
DHS 157.74(2)(g) (g) When a patient or film must be provided with additional support during a radiation exposure, all of the following applies:
DHS 157.74(2)(g)1. 1. The human holder shall be instructed in personal radiation safety and protected as required by subd. 2. Written safety procedures are required.
DHS 157.74(2)(g)2. 2. In those cases where the patient must hold the film, any portion of the body other than the area of clinical interest struck by the useful beam shall be protected by not less than 0.5 millimeter lead equivalent material.
DHS 157.74(2)(g)3. 3. Each facility shall have leaded shielding garments and devices available in sufficient numbers to provide protection to all personnel who are involved with x-ray operations and who are otherwise not shielded.
DHS 157.74(2)(g)4. 4. Leaded shielding garments and devices shall be fluoroscopically or radiographically inspected at least every 2 years for defects and replaced if defective.
DHS 157.74(2)(g)5. 5. If visual inspection reveals possible defects, radiographic or fluoroscopic inspections shall be performed.
DHS 157.74 Note Note: Leaded shielding garments and devices include aprons, gloves, vests, skirts, thyroid shields and gonadal shields.
DHS 157.74(2)(h) (h) Procedures and auxiliary equipment designed to minimize patient and personnel exposure commensurate with the needed diagnostic information shall be utilized, as follows:
DHS 157.74(2)(h)1. 1. The speed of the screen and film combinations used shall be of a speed consistent with the diagnostic objective of the examinations. Film cassettes without intensifying screens may not be used for any routine diagnostic radiological imaging, with the exception of veterinary radiography and standard film packets for intra-oral use in dental radiography.
DHS 157.74(2)(h)2. 2. The radiation exposure to the patient shall be the minimum exposure required to produce images of good diagnostic quality.
DHS 157.74(2)(h)3. 3. An x-ray system may not be utilized in a procedure where the source to patient distance is less than 30 centimeters, except for a veterinary system, bone density unit or a unit granted an exemption by the US food and drug administration.
DHS 157.74(2)(h)4. 4. If grids are used between the patient and the image receptor to decrease scatter to the film and improve contrast, the grid shall meet all of the following requirements:
DHS 157.74(2)(h)4.a. a. Be positioned with tube side facing the in right direction, and grid centered to the central ray.
DHS 157.74(2)(h)4.b. b. Be of the proper focal distance for the SIDs being used. Grids shall be of the proper ratio to adequately reduce scatter for the procedure being performed.
DHS 157.74(2)(h)4.c. c. Antiscatter grids or an appropriate air gap technique to reduce scatter to the image receptor shall be used for all x-ray examinations of the human torso utilizing stationary x-ray equipment for patients 12 years of age or older.
DHS 157.74(2)(i) (i) All persons associated with the operation of an x-ray system are subject to the requirements of s. DHS 157.22 (1), (5), (7) and (8).
DHS 157.74(2)(j) (j) A person proposing to conduct a healing arts screening program may not initiate a program without the department's prior approval. When requesting approval, the person shall submit the information outlined in Appendix M. If any information submitted to the department becomes invalid or outdated, the department shall be immediately notified.
DHS 157.74(2)(k) (k) All facilities performing mammography shall meet the requirements of 21 CFR 900, US food and drug administration, Mammography Quality Standards Act.
DHS 157.74(2)(L) (L) A registrant that uses two or more therapeutic radiation machines for human use shall establish a radiation safety committee consisting of at least three members to oversee the use of all therapeutic radiation machines. The committee shall include an operator authorized by the registrant, a representative of the institution's management, and the radiation safety officer. If the institution has a radiation safety committee established under s. DHS 157.61 (1) (e), this committee may be designated to oversee the use of all therapeutic radiation machines, if an operator authorized by the registrant is appointed to this committee.
DHS 157.74(3) (3)X-ray image processing equipment and processing procedures.
DHS 157.74(3)(a)1.1. Each installation using a radiographic x-ray system for human diagnosis or screening and using analog image receptors shall have available suitable equipment for handling and processing radiographic film according to the film and chemistry manufacturer's instructions.
DHS 157.74(3)(a)2. 2. Quality control and maintenance procedures shall be performed on a regular schedule according to the device manufacturer's recommendations.
DHS 157.74(3)(a)3. 3. X-ray film processing control tests shall be performed and analyzed on days when human patient films are being processed and prior to the processing of the first films of the day, except dental and podiatry facilities. If analysis shows that the image quality has declined, corrective action shall be taken prior to processing patient films.
DHS 157.74(3)(a)4. 4. X-ray film processors in dental and podiatry facilities shall be tested at least once a week.
DHS 157.74(3)(b) (b) Digital imaging systems.
DHS 157.74(3)(b)1.1. Each installation using a digital radiographic x-ray system for human diagnosis or screening shall have available suitable equipment for handling and processing the radiographic digital image according to the manufacturer's instructions.
DHS 157.74(3)(b)2. 2. Quality control and maintenance procedures shall be performed on a regular schedule according to the device manufacturer's recommendations. If analysis shows that the system test results fall outside the device manufacturer's recommended limits corrective action shall be taken prior to performing patient examinations.
DHS 157.74(4) (4)Other requirements.
DHS 157.74(4)(a)(a) Pass boxes, if provided, shall be constructed to exclude light from the darkroom when cassettes are placed in or removed from the boxes and shall incorporate adequate shielding from stray radiation to prevent exposure of undeveloped film.
DHS 157.74(4)(b) (b) The darkroom shall be light tight with proper safelights so that any film type in use exposed in a cassette to x-radiation sufficient to produce an optical density from one to 2 when processed may not suffer an increase in density greater than 0.1, or 0.05 for mammography, when exposed in the darkroom for 2 minutes with all safelights on. This test shall be performed at least once every 6 months. If used, daylight film handling boxes shall preclude fogging of the film. Darkrooms typically used by more than one person shall be provided a method to prevent accidental entry while undeveloped films are being handled or processed.
DHS 157.74(4)(c) (c) Film shall be stored according to the manufacturer's requirements and shall be protected from exposure to stray radiation. Film in open packages shall be stored in a light tight container.
DHS 157.74(4)(d) (d) Film cassettes and intensifying screens shall be inspected periodically and shall be cleaned and replaced as necessary and consistent with the manufacturer's instructions to best assure radiographs of good diagnostic quality.
DHS 157.74(4)(e) (e) Outdated x-ray film may not be used for diagnostic radiographs.
DHS 157.74(4)(f) (f) Film developing solutions shall be prepared using instructions given by the manufacturer and maintained in strength by replenishment or renewal so that full development is accomplished within the time specified by the manufacturer.
DHS 157.74 History History: CR 01-108: cr. Register July 2002 No. 559, eff. 8-1-02; CR 06-021: am. (2) (b) (intro.), (g) 3., 4., (3) (c) and (4) (b), cr. (2) (d) 3. and (g) 5. Register October 2006 No. 610, eff. 11-1-06; CR 09-062: am. (2) (g) 4. and (3) (title), cr. (2) (L), (3) (a) (title) and (b), renum. (3) (a) to (d) to be (3) (a) 1. to 4. Register April 2010 No. 652, eff. 5-1-10.
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.