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Standards of Practice |
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Overview
Introduction
1. Legislation, Standards and Ethics
2. Equipment and Materials
3. Diagnostic and Therapeutic Procedures
4. Safe Practice
5. Relationship with Patients
6. Professional Relationships
7. Records and Reporting
8. Continuing Competence
7. Records and Reporting
Creating and maintaining records and reports are essential components of the professional practice of MRTs. MRTs’ records and reports provide information to other health care professionals about relevant aspects of patient care, treatment and assessment.
Practice Standard: MRTs must be proficient in creating records, charts, incident and other reports that attest to the diagnostic, treatment, quality assurance, workplace and patient safety procedures that have been carried out. MRTs must have the knowledge, skills and judgement to record information that will adequately identify the subjects of all the images and data they create and treatments they administer. MRTs must produce records and reports that are accurate, complete, legible and timely.
Indicators
MRTs must:
| a) |
record results of quality control tests |
| b) |
record and report any equipment faults or problems |
| c) |
record and notify the patient's physician, radiologist, nuclear medicine physician or radiation oncologist of any allergies, abnormal test results or other contraindications to the ordered procedure |
| d) |
mark all images and data with the patient’s identity |
| e) |
ensure all images and data are archived according to principles and guidelines established by the employment facility |
| f) |
record the patient’s reactions to the treatment or procedure or any administered substances |
| g) |
record all pertinent aspects of patient care and all procedures performed, including emergency treatments and descriptions of, and reasons for, any deviations from standard procedures on order forms, treatment prescriptions, patient charts or other relevant documentation |
| h) |
forward patients' records, images and pertinent data to appropriate recipients |
| i) |
record and inform patient and/or members of the health care team of any follow-up care required |
In addition, MRTs in the specialty of nuclear medicine and radiation therapy must:
| j) |
record results of radiopharmaceutical assays, quality control and other tests, radioactive preparations and disposal methods of radioactive materials |
In addition, MRTs in the specialty of nuclear medicine must:
| k) |
record receipt and disposal of radiopharmaceuticals, generators and radioactive materials |
| l) |
label radiopharmaceutical preparations |
| m) |
maintain radiopharmaceutical and pharmaceutical dispensing records |
In addition, MRTs in the specialty of radiation therapy must:
| n) |
record and communicate any concerns regarding the treatment or treatment prescription to the appropriate radiation oncology personnel |
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