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Accreditation for Medicare Deemed Status
13. Diagnostic and Other Imaging Services Standards
13.L. Diagnostic imaging tests are performed, authenticated, and documented appropriately.
13.L.5. Reports as part of the patient's clinical record
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13. Diagnostic and Other Imaging Services Standards
13.A. Condition for Coverage - Laboratory and radiologic services.
13.A. Resources
13.B. If radiologic services are utilized, the governing body must appoint an individual qualified in accordance with State law and ASC policies who is responsible for assuring all radiologic services are provided in accordance with the requirements of this section.
13.B. Resources
13.D. The radiologic services must meet the requirements specified in Parts 482.26(b), (c)(2), and (d)(2) of CMS Hospital Conditions of Participation.
13.D.1. Free from hazards for patients and personnel
13.D.2. Personnel designated as qualified
13.D.3. Report copies maintained for 5 years
13.D.4. Image records maintained for 5 years
13.E. Health care professionals providing imaging services and/or interpreting results are appropriately trained and privileged.
13.E.3. Documentation of safety training
13.F. Imaging services provided are appropriate to the needs of patients and support the organization's clinical capabilities.
13.F.2. Record and report maintenance
13.G. Written policies and procedures addressing safety aspects of imaging services are present.
13.G.1. Precautions for potential hazards
13.G.2. Periodic evaluation of safety measures
13.H. Written policies and procedures address the management of potentially hazardous energy sources.
13.H.1. Compliance with laws and regulations
13.H.2. Proper shielding for use of energy sources
13.H.4. Radiation exposure records
13.L. Diagnostic imaging tests are performed, authenticated, and documented appropriately.
13.L.5. Reports as part of the patient's clinical record
13.M. Diagnostic images are accessible and appropriately retained and stored.
13.M.1. Policy on image storage and retention
13.N. If magnetic resonance imaging is conducted, proper warning signs are in place.
13.N.1. Warning for patients/personnel with metal implants
13.N.4. Warning for patients/personnel with implanted electromechanical devices
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Element of Compliance
Reports as part of the patient's clinical record
Documentation Required
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