How do you handle Radiologist signing orders. We currently go by how the provider orders unless it does not match our protocols and then we check with the provider. If there is no specification on contrast use we follow our protocols. We normally only check with the Radiologist when lab values are off or the order does not make sense. How does Hopkins do it to comply with Joint Commission? We give all patients 100ml of Omnipaque unless they are under 100lbs then 1cc per pound.
This question is in reference to contrast and drugs administered in the imaging setting. The medications are all administered by protocol and not ordered by a radiologist. Therefore, there is no documentation in the medical record at this time. Are we in compliance with this process? Thank you for your help.
Thank you for your inquiry. The scenario you describe is not compliant with Joint Commission Standards. There are several issues for consideration. 1. PC.02.01.03 EP 1 states "For hospitals that use Joint Commission accreditation for deemed status purposes: Prior to providing care, treatment, and services, the hospital obtains or renews orders (verbal or written) from a licensed independent practitioner in accordance with professional standards of practice and law and regulation." 2. RC.01.01.01 EP 7 states "The medical record contains information that documents the course and result of the patient's care, treatment, and services." 3. Regarding protocols: Protocols must be approved by the medical staff and may be initiated based on pre-established and approved assessment criteria in order to provide timely care and services to patients. Protocols should be used to delineate care and not used merely for convenience. The use of the protocol must be documented as an order in the patient's medical record and signed by the practitioner responsible for the care of the patient. However, the timing of such documentation should not be a barrier to providing timely and necessary care, or other patient safety advances. 4. I am also including the following excerpt regarding contrast media that was printed in the June 2005 Perspectives Newsletter: Contrast media are considered a medication. The administration of oral contrast media without prior pharmacist review has been determined to be safe, a standard of practice by pharmacists and the