1. (1)(a) The licensee shall provide an organized radiology department offering services that are in accordance with the needs and size of the institution.

   1. (b) A person appointed and authorized by the hospital administrator shall direct the radiology services.

   2. (c)(i) A member of the medical staff shall provide medical direction of the department.

      1. (ii) If a radiologist is not the medical director of the radiology services, the licensee shall retain the services of a radiologist.
      2. (iii) If a radiologist provides services on less than a full-time basis, the time commitment shall allow the radiologist to complete the necessary functions to meet the radiological needs of the patients and the medical staff.

   3. (d) The radiologist shall:

      1. (i) assure the availability of information regarding the purpose and yield of radiological procedures and the risks of radiation;
      2. (ii) develop technique charts that include part, thickness, exposure factors, focal film distances, and either a grid or screen technique; and
      3. (iii) maintain a quality control program that minimizes unnecessary duplication of radiographic studies and maximizes the quality of diagnostic information available.
   4. (e) The licensee shall ensure at least one licensed radiologic technologist is on duty or available as needed.
   5. (f) Only a member of the medical staff or other person authorized by the hospital shall authorize the performance of diagnostic radiology services.

   6. (g) If the licensee provides radiation oncology services, the following shall apply:

      1. (i) physicians and staff who provide radiation oncology services have delineated privileges; and
      2. (ii) the medical director of the radiation oncology services is a physician member of the medical staff who is qualified by education and experience in radiation oncology.

2. (2)(a) The licensee shall integrate radiologic medical with the hospital patient record.

   1. (b) Any request for radiologic services shall contain the reasons for the examinations.
   2. (c) The licensee shall file authenticated reports of these examinations in the patient's medical record as soon as possible.
   3. (d) The licensee shall keep radiological film in accordance with hospital policy.
   4. (e) If requested by the attending physician and if the quality of the radiograph permits, the radiology department may officially enter the interpretations of the radiologic examinations performed outside of the hospital in the patient's medical record.

   5. (f)(i) The licensee shall file radiotherapy summaries as follows:

      1. (A) documented in the medical record of the patient receiving radiotherapy for treatment or palliation of a malignancy and reflect the histologically substantiated diagnosis, unless otherwise justified;
      2. (B) in the patient's medical record; and
      3. (C) forwarded to the referring physician.
      4. (ii) The licensee may additionally file radiotherapy summaries in the radiotherapy department.

KEY: health care facilities

Date of Last Change: June 5, 2026

Notice of Continuation: August 22, 2025

Authorizing, and Implemented or Interpreted Law: 26B-1-202; 26B-2-202; 26B-2-203