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Hi Jill, TJC fluoroscopy skin dose threshold used to be the sentinel event trigger. They updated the sentinel event definition, eliminating an explicitly threshold (no longer the 15 Gy within 6 months to one year) and replacing it with (paraphrasing)</div>
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<div dir="ltr">Hi Jill,<div><br></div><div>TJC fluoroscopy skin dose threshold used to be the sentinel event trigger. They updated the sentinel event definition, eliminating an explicitly threshold (no longer the 15 Gy within 6 months to one year) and replacing it with (paraphrasing) cases in which a skin burn occurs AND resulted from inappropriate use of fluoroscopy. </div><div><br></div><div>Daniel</div></div><br><div class="gmail_quote gmail_quote_container"><div dir="ltr" class="gmail_attr">On Thu, Apr 16, 2026 at 6:22 AM Shuman, Jill via Intl_dxmedphys_wd_osu_list <<a href="mailto:intl_dxmedphys_wd_osu_list@lists.osu.edu">intl_dxmedphys_wd_osu_list@lists.osu.edu</a>> wrote:<br></div><blockquote class="gmail_quote" style="margin:0px 0px 0px 0.8ex;border-left:1px solid rgb(204,204,204);padding-left:1ex"><div class="msg-2137068673815236202">
<div style="font-size:1px;color:rgb(255,255,255);line-height:1px;max-height:0px;opacity:0;overflow:hidden;display:none">
I’ve been updating my TJC documentation with what points to where now following the 1/2026 TJC updates and noticed that the Joint Commission eliminated the EP for fluoro skin dose thresholds? Can anyone tell me if it’s still around</div>
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<p class="MsoNormal"><span style="font-size:1pt;color:white">I’ve been updating my TJC documentation with what points to where now following the 1/2026 TJC updates and noticed that the Joint Commission eliminated the EP for
fluoro skin dose thresholds? Can anyone tell me if it’s still around<u></u><u></u></span></p>
</div>
<div>
<p class="MsoNormal"><span style="font-size:11pt">I’ve been updating my TJC documentation with what points to where now following the 1/2026 TJC updates and noticed that the Joint Commission eliminated the EP for fluoro skin
dose thresholds? Can anyone tell me if it’s still around and what the new EP is?
</span><span style="font-size:1pt"><u></u><u></u></span></p>
</div>
<p class="MsoNormal"><span style="font-size:11pt"><u></u> <u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt">More notes below for those curious.<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt"><u></u> <u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt"><u></u> <u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt">From the hospital crosswalk document:<u></u><u></u></span></p>
<p class="MsoNormal"><img width="1544" height="192" style="width: 16.0833in; height: 2in;" id="m_-2137068673815236202Picture_x0020_1" src="cid:ii_19d9d3a27db4cff311"><span style="font-size:11pt"><u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt"><u></u> <u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt">The “new” EP replacing this EP seems to essentially say the radiation safety officer is responsible for stopping unsafe practices and creating policies. I would assume that all institutions have a fluoro skin
dose policy now, I just think it’s interesting the specific EP requesting that documentation has disappeared.
<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt"><u></u> <u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt">The only place left in the survey process guide asking for fluoroscopy dose states:<u></u><u></u></span></p>
<p class="MsoNormal"><b><span style="font-size:11pt">Reports, including medical record number, documenting fluoroscopy radiation dose for 5 recent inpatients. RC.12.1.1 EP 2
<u></u><u></u></span></b></p>
<p class="MsoNormal"><span style="font-size:11pt"><u></u> <u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt">RC.12.1.1 EP 2:<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt">The medical record contains the following clinical information:<br>
- Admitting diagnosis<br>
- Any emergency care, treatment, and services provided to the patient before their arrival<br>
- Any allergies to food and medications<br>
- Any findings of assessments and reassessments<br>
- Results of all consultative evaluations of the patient and findings by clinical and other staff involved in the care of the patient<br>
- Treatment goals, plan of care, and revisions to the plan of care<br>
- Documentation of complications, health care–acquired infections, and adverse reactions to drugs and anesthesia<br>
- All practitioners' orders<br>
- Nursing notes, reports of treatment, laboratory reports, vital signs, and other information necessary to monitor the patient's condition<br>
- Medication records, including the strength, dose, route, date and time of administration, access site for medication, administration devices used, and rate of administration<br>
Note: When rapid titration of a medication is necessary, the hospital defines in policy the urgent/emergent situations in which block charting would be an acceptable form of documentation. For the definition and a further explanation of block charting, refer
to the Glossary.<br>
- Administration of each self-administered medication, as reported by the patient (or the patient’s caregiver or support person where appropriate)<br>
- <b>Records of radiology and nuclear medicine services, including signed interpretation reports</b><br>
- All care, treatment, and services provided to the patient<br>
- Patient’s response to care, treatment, and services<br>
- Medical history and physical examination, including any conclusions or impressions drawn from the information<br>
- Discharge plan and discharge planning evaluation<br>
- Discharge summary with outcome of hospitalization, disposition of case, and provisions for follow-up care, including any medications dispensed or prescribed on discharge<br>
- Any diagnoses or conditions established during the patient’s course of care, treatment, and services<br>
Note: Medical records are completed within 30 days following discharge, including final diagnosis.<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt"><u></u> <u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt"><u></u> <u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt">None of RC.12.1.1 EP 2 would indicate to me any dose documentation is required but I know CMS has a MIPS measure for it (Quality ID #145).<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt"><u></u> <u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt">I’m not looking to eliminate any skin dose thresholds at my institution, I’m mostly just curious as to why the joint commission would eliminate it (or where it is if they didn’t eliminate it).
<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt"><u></u> <u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt">Thanks,<u></u><u></u></span></p>
<p class="MsoNormal"><span style="font-size:11pt">Jill<u></u><u></u></span></p>
<p><u></u> <u></u></p>
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</div></blockquote></div><div><br clear="all"></div><div><br></div><span class="gmail_signature_prefix">-- </span><br><div dir="ltr" class="gmail_signature">Daniel Vergara<div><div><a href="mailto:xvergarax@gmail.com" target="_blank">xvergarax@gmail.com</a></div><div><br></div></div></div>