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Hi all, This TJC site is helpful and includes standard /EP requirements, cross walks, disposition reports, and Survey Process Guides (SPGs). The TJC Disposition Report tracks where prior EPs have been moved, consolidated, or split. We found</div>
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<p style="direction: ltr; line-height: normal; margin: 0px; min-height: 14px;"><span style="font-size: 16px; color: rgb(0, 0, 0);">Hi all,</span></p>
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</p>
<p style="direction: ltr; line-height: normal; margin: 0px; min-height: 14px;"><span style="font-size: 16px; color: rgb(0, 0, 0);"><a href="https://urldefense.com/v3/__https://www.jointcommission.org/en-us/accreditation/accreditation-360/prepublication-cah-and-hap-requirements-streamlined-to-reduce-burden__;!!KGKeukY!yVbGPIzWr_rsX8sQNhwAHdteaKwen0hz37Bjh8dlQNxYgYZ_jc5_1gZwcdoDFANhZ0wBdciTM208f1KXc4Kve1c7SkRfJX9G5pdS5E9AfNiVUx1mSzw$" data-outlook-id="970a76d4-af84-4a70-a294-2c23197f0d9d" style="margin-top: 0px; margin-bottom: 0px;">This
TJC site</a><a href="https://urldefense.com/v3/__https://www.jointcommission.org/en-us/accreditation/accreditation-360/prepublication-cah-and-hap-requirements-streamlined-to-reduce-burden__;!!KGKeukY!yVbGPIzWr_rsX8sQNhwAHdteaKwen0hz37Bjh8dlQNxYgYZ_jc5_1gZwcdoDFANhZ0wBdciTM208f1KXc4Kve1c7SkRfJX9G5pdS5E9AfNiVUx1mSzw$" data-outlook-id="aec6482c-6f59-4b70-b34f-547995b96726" style="text-decoration: none; margin-top: 0px; margin-bottom: 0px;">
</a>is helpful and includes standard /EP requirements, cross walks, disposition reports, and Survey Process Guides (SPGs). </span></p>
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<div><span style="font-size: 16px;">The TJC Dispositi</span><span style="font-family: Aptos, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">on Report tracks where prior EPs have been moved, consolidated, or split. </span></div>
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We found other relevant EPs that were affected, including lightened requirements for shielding, fluoroscopy CAK documentation, and CT dose documentation. It is helpful to review these against your state requirements and hospital policies. Also importantly,
some EPs have been removed from formal accreditation standards and are now addressed within the SPG. As a result, some compliance expectations persist even when a specific standard is no longer available as a direct reference point.</div>
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The Disposition Report lists the former fluoroscopy skin dose review EP was replaced with a general radiation safety oversight for radiologic services and compliance/recommendation/interventions related to radiation safety practices:</div>
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<img src="cid:1492D69B-9AD9-494A-AE33-85ACBBD92295" alt="image.png" id="image_2" width="884" height="113" style="width: 884.847458px; height: 113px;"></div>
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Also, here is a relevant update regarding CAK documentation:</div>
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<img src="cid:9523B236-BA80-48C6-AFE2-5BE4AEB9213F" alt="image.png" id="image_1" width="881" height="233" style="width: 881.933884px; height: 233px;"></div>
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The SPG states the organization should be able to present the surveyor medical records with documented fluoro radiation dose for 5 recent inpatients:</div>
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<img src="cid:03882DE6-3140-4264-B671-8BC5A69F5548" alt="image.png" id="image_3_0" width="663" height="54" style="width: 663px; height: 54px;"> </div>
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<img src="cid:362C2370-D717-4BEB-951C-1FC03572F8F3" alt="image.png" id="image_3" width="663" height="85" style="width: 663px; height: 85px; max-width: 1076px;"> </div>
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The TJC Sentinel Event Policy also continues to identify the following as a SE, referencing NCRP Statement 11:</div>
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<img src="cid:C796FBF4-5B59-425B-803E-D9A412991D36" alt="image.png" id="image_0" width="622" height="66" style="width: 622px; height: 66px;"></div>
<p style="line-height: normal; margin: 0px;"><span style="color: rgb(0, 0, 0);"> <img src="cid:8A802C1A-2750-4C5F-8730-BB196777710A" alt="image.png" id="id-8A802C1A-2750-4C5F-8730-BB196777710A" width="469" height="54" style="width: 469px; height: 54px; max-width: 100%; margin-top: 0px; margin-bottom: 0px;"></span></p>
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As requirements evolve and standards are streamlined, our expertise and influence become increasingly valuable. Our understanding of the evidence, regulations, and best practices that support safe, high-quality care will remain essential in ensuring important
principles continue to guide patient care.</div>
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Best regards,</div>
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<div style="font-family: Aptos, Arial, Helvetica, sans-serif; font-size: 12pt; color: rgb(0, 0, 0);">
Izabella</div>
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<span style="line-height: 1.2;"><b>Izabella Barreto, PhD, MBA, DABR, DABSNM</b></span></div>
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<span style="line-height: 1.2;">Division Chief of Medical Physics</span></div>
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<span style="line-height: 1.2;">Associate Professor of Radiology and Imaging Sciences</span></div>
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<span style="line-height: 1.2;">Department of Radiology and Imaging Sciences</span></div>
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<span style="line-height: 1.2;">Emory University School of Medicine</span></div>
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<span style="line-height: 1.2;">Cell: (407) 529-7960 </span></div>
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<span style="line-height: 1.2;">Email: <a href="mailto:Izabella.Barreto@emory.edu" title="mailto:Izabella.Barreto@emory.edu" data-outlook-id="6d34e8ed-ba2d-45a2-92f9-903b4f36fcea" style="color: rgb(23, 78, 134);">
Izabella.Barreto@emory.edu</a></span></div>
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<div style="font-family: Arial, Helvetica, sans-serif; font-size: 9pt;"><span style="color: rgb(23, 78, 134); line-height: 1.2;">Visit our Medical Physics
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<b>From: </b>Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces@lists.osu.edu> on behalf of Lemieux, Bryan P. via Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list@lists.osu.edu><br>
<b>Date: </b>Monday, August 24, 2026 at 10:31 AM<br>
<b>To: </b>Johnson, Loretta M <lorettajohnson@uabmc.edu>; Stephanie M. Leon <Stephanie.M.Leon@hitchcock.org>; intl_dxmedphys_wd_osu_list@lists.osu.edu <intl_dxmedphys_wd_osu_list@lists.osu.edu><br>
<b>Subject: </b>[External] Re: [Intl_DxMedPhys] EXT MSG Re: Requirement for dose monitoring<br>
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<span style="font-size: 12pt;">Your state may still have a requirement for dose documentation, possibly in terms of at least fluoro time. </span></p>
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<span style="font-size: 12pt;"> </span></p>
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<span style="font-size: 12pt;">Also, while JC removed some things, they still have a Sentinel Event for patient burns (which includes radiation burns). I would be very interested if anyone has a way to effectively and proactively identify, investigate and
intervene in possible patient radiation burns that is not tied to dose monitoring………</span></p>
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<span style="font-size: 12pt;"> </span></p>
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<span style="font-size: 12pt;">Its also tied to some quality measures.</span></p>
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<span style="font-size: 12pt;"> </span></p>
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<span style="font-size: 12pt; color: black;">Bryan Lemieux MS CHP DABMP</span></p>
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<span style="font-size: 12pt; color: black;">Associate Chief for Radiation Safety</span></p>
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<span style="font-size: 12pt; color: black;">Radiation Safety Officer</span></p>
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<span style="font-size: 12pt; color: black;">UK HealthCare</span></p>
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<span style="font-family: Calibri, sans-serif; font-size: 11pt;"><b>From:</b> Intl_dxmedphys_wd_osu_list <intl_dxmedphys_wd_osu_list-bounces+bryan.lemieux=uky.edu@lists.osu.edu>
<b>On Behalf Of </b>Johnson, Loretta M via Intl_dxmedphys_wd_osu_list<br>
<b>Sent:</b> Monday, August 24, 2026 9:52 AM<br>
<b>To:</b> Stephanie M. Leon <Stephanie.M.Leon@hitchcock.org>; intl_dxmedphys_wd_osu_list@lists.osu.edu<br>
<b>Subject:</b> Re: [Intl_DxMedPhys] EXT MSG Re: Requirement for dose monitoring</span></p>
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<span style="font-family: Calibri, sans-serif; font-size: 11pt; color: rgb(156, 101, 0); background-color: rgb(255, 235, 156);"><b>CAUTION:</b></span><span style="font-family: Calibri, sans-serif; font-size: 11pt; color: black; background-color: rgb(255, 235, 156);"><b>
External Sender</b></span></p>
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<span style="font-size: 1pt; color: white;">Is your radiation safety officer going to allow them to opt out of dose monitoring? Peace, Loretta Loretta Johnson, Ph.</span><span style="font-family: Arial, sans-serif; font-size: 1pt; color: white;"> </span><span style="font-size: 1pt; color: white;">D.</span><span style="font-family: Arial, sans-serif; font-size: 1pt; color: white;"> </span><span style="font-size: 1pt; color: white;">,
DABR, FAAPM | Associate Professor Division of Imaging Physics Department of Radiology | Heersink School of Medicine UAB</span></p>
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<span style="font-size: 11pt;">Is your radiation safety officer going to allow them to opt out of dose monitoring?</span></p>
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<span style="font-size: 12pt; color: black;">Peace,</span></p>
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<span style="font-size: 12pt; color: black;">Loretta</span></p>
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<span style="font-size: 12pt; color: rgb(26, 86, 50);"><b>Loretta Johnson, Ph.D., DABR, FAAPM | Associate Professor</b></span></p>
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<span style="font-size: 12pt;">Division of Imaging Physics</span></p>
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<span style="font-size: 12pt;">Department of Radiology | Heersink School of Medicine</span></p>
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<span style="font-size: 12pt;">UAB | The University of Alabama at Birmingham</span></p>
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<span style="font-size: 12pt;">GSB Suite #301 | 619 19<sup>th</sup> Street South | Birmingham, AL 35249</span></p>
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<span style="font-size: 12pt;">P: 205.934.7592 |</span><span style="font-size: 12pt; color: rgb(26, 86, 50);">
<a href="mailto:lorettajohnson@uabmc.edu" data-outlook-id="3683fc49-08f4-435a-8430-57f4dee51f6b" style="color: rgb(26, 86, 50); margin-top: 0px; margin-bottom: 0px;">
<u>lorettajohnson@uabmc.edu</u></a></span></p>
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<span style="font-size: 12pt; color: rgb(26, 86, 50);"><a href="https://urldefense.com/v3/__https://www.uab.edu/medicine/radiology/__;!!KGKeukY!3PpNQTSRa_7oyKwYbJ4SBQyUn3EybE5XnTsIdRV49Iqbm_WqxuWioHJ6jRdJeAOI4wTBfHQTTMlZbsDXD_cXyVOiMeugkrF_s5vS8hYQlGKFQlVrvQ$" originalsrc="https://urldefense.com/v3/__https://www.uab.edu/medicine/radiology/__;!!KGKeukY!3PpNQTSRa_7oyKwYbJ4SBQyUn3EybE5XnTsIdRV49Iqbm_WqxuWioHJ6jRdJeAOI4wTBfHQTTMlZbsDXD_cXyVOiMeugkrF_s5vS8hYQlGKFQlVrvQ$" data-outlook-id="1e89200f-e6ed-4550-a771-4ffebc6fe16c" style="color: rgb(26, 86, 50); margin-top: 0px; margin-bottom: 0px;"><u>https://www.uab.edu/medicine/radiology/</u></a></span></p>
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<span style="font-family: Calibri, sans-serif; color: black;"><b>From: </b>Intl_dxmedphys_wd_osu_list <</span><span style="font-family: Calibri, sans-serif; color: blue;"><a href="mailto:intl_dxmedphys_wd_osu_list-bounces+lorettajohnson=uabmc.edu@lists.osu.edu" data-outlook-id="b96b039a-27c5-458f-ae25-3beb6e54c294" style="color: blue; margin-top: 0px; margin-bottom: 0px;"><u>intl_dxmedphys_wd_osu_list-bounces+lorettajohnson=uabmc.edu@lists.osu.edu</u></a></span><span style="font-family: Calibri, sans-serif; color: black;">>
on behalf of Dxmedphys new list <</span><span style="font-family: Calibri, sans-serif; color: blue;"><a href="mailto:intl_dxmedphys_wd_osu_list@lists.osu.edu" data-outlook-id="e47371f9-48d1-449d-9db1-17e8046e1721" style="color: blue; margin-top: 0px; margin-bottom: 0px;"><u>intl_dxmedphys_wd_osu_list@lists.osu.edu</u></a></span><span style="font-family: Calibri, sans-serif; color: black;">><br>
<b>Reply-To: </b>"Stephanie M. Leon" <</span><span style="font-family: Calibri, sans-serif; color: blue;"><a href="mailto:Stephanie.M.Leon@hitchcock.org" data-outlook-id="0a27d2e0-8a68-4faa-9bac-6f237175a7ad" style="color: blue; margin-top: 0px; margin-bottom: 0px;"><u>Stephanie.M.Leon@hitchcock.org</u></a></span><span style="font-family: Calibri, sans-serif; color: black;">><br>
<b>Date: </b>Tuesday, August 11, 2026 at 2:21 PM<br>
<b>To: </b>Dxmedphys new list <</span><span style="font-family: Calibri, sans-serif; color: blue;"><a href="mailto:intl_dxmedphys_wd_osu_list@lists.osu.edu" data-outlook-id="e4308b51-9565-461c-ac22-baa18ae2c705" style="color: blue; margin-top: 0px; margin-bottom: 0px;"><u>intl_dxmedphys_wd_osu_list@lists.osu.edu</u></a></span><span style="font-family: Calibri, sans-serif; color: black;">><br>
<b>Subject: </b>EXT MSG Re: [Intl_DxMedPhys] Requirement for dose monitoring</span></p>
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<span style="font-size: 1pt; color: white;">Thanks to all who responded already! I was not imagining that there used to be a relevant TJC requirement. However, it is gone now. Stephanie M. Leon, PhD, DABR, DABSNM Chief of Diagnostic Medical Physics Associate
Professor of Radiology Tel</span></p>
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<span style="font-size: 12pt;">Thanks to all who responded already! I was not imagining that there used to be a relevant TJC requirement. However, it is gone now.</span></p>
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<span style="font-family: Arial, sans-serif; font-size: 12pt; color: rgb(99, 144, 68);"><b>Stephanie M. Leon, PhD, DABR, DABSNM</b></span></p>
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<span style="font-family: Arial, sans-serif; font-size: 12pt; color: rgb(0, 102, 79);">Chief of Diagnostic Medical Physics</span></p>
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<span style="font-family: Arial, sans-serif; font-size: 12pt; color: rgb(0, 102, 79);">Associate Professor of Radiology<br>
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<span style="font-family: Arial, sans-serif; font-size: 12pt; color: rgb(0, 102, 79);">Tel (603) 650-3796<br>
</span><span style="font-family: Arial, sans-serif; font-size: 12pt; color: blue;"><a href="https://urldefense.com/v3/__http:/Dartmouth-Health.org__;!!NoSwA-eRAg!ADcCl68OJkbTYrpBcJWbdN0QvZLTKoxmyLXo7HFBGr6jJOOC8jno2gtBrDZVcr590IbKEZJ--nwqMSQ1Tk4F4Qsbsk-RFLnqnNlX6Q$" originalsrc="https://urldefense.com/v3/__http:/Dartmouth-Health.org__;!!NoSwA-eRAg!ADcCl68OJkbTYrpBcJWbdN0QvZLTKoxmyLXo7HFBGr6jJOOC8jno2gtBrDZVcr590IbKEZJ--nwqMSQ1Tk4F4Qsbsk-RFLnqnNlX6Q$" data-outlook-id="0f0a2900-40dd-41a8-8a4b-067f07355177" style="color: blue; margin-top: 0px; margin-bottom: 0px;"><u>Dartmouth-Health.org</u></a></span></p>
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<span style="font-family: Arial, sans-serif; font-size: 9pt; color: rgb(127, 127, 127);"><a href="https://urldefense.com/v3/__https:/www.dartmouth-health.org/__;!!KGKeukY!yTuIAOaPrlYFdbY1HfZEUyQF7tjiw18b0c0FqOji4JUOSdBLQjHyjlD2hUIMYv2EUIPj-IJa92UrMuzjG9Vw_aiyig36-fHnY0mT9h4wCOyCJtaZP7oJrQ$" originalsrc="https://urldefense.com/v3/__https:/www.dartmouth-health.org/__;!!KGKeukY!yTuIAOaPrlYFdbY1HfZEUyQF7tjiw18b0c0FqOji4JUOSdBLQjHyjlD2hUIMYv2EUIPj-IJa92UrMuzjG9Vw_aiyig36-fHnY0mT9h4wCOyCJtaZP7oJrQ$" data-outlook-id="622a331e-80b5-4fef-8239-9f1ed2882308" style="color: rgb(127, 127, 127); margin-top: 0px; margin-bottom: 0px;"><u><img src="cid:image001.png@01DD33B3.1E610420" id="Picture_x0020_1" width="211" height="60" style="width: 2.2in; height: 0.625in; margin-top: 0px; margin-bottom: 0px;"></u></a></span></p>
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<span style="font-family: Calibri, sans-serif; font-size: 11pt;"><b>From:</b> Intl_dxmedphys_wd_osu_list <</span><span style="font-family: Calibri, sans-serif; font-size: 11pt; color: blue;"><a href="mailto:intl_dxmedphys_wd_osu_list-bounces@lists.osu.edu" data-outlook-id="88421f56-6582-4417-9a52-e6866a39aef7" style="color: blue; margin-top: 0px; margin-bottom: 0px;"><u>intl_dxmedphys_wd_osu_list-bounces@lists.osu.edu</u></a></span><span style="font-family: Calibri, sans-serif; font-size: 11pt;">>
<b>On Behalf Of </b>Stephanie M. Leon via Intl_dxmedphys_wd_osu_list<br>
<b>Sent:</b> Tuesday, August 11, 2026 2:42 PM<br>
<b>To:</b> </span><span style="font-family: Calibri, sans-serif; font-size: 11pt; color: blue;"><a href="mailto:intl_dxmedphys_wd_osu_list@lists.osu.edu" data-outlook-id="6af6030b-0e28-4fb5-a8ad-e6360f77469f" style="color: blue; margin-top: 0px; margin-bottom: 0px;"><u>intl_dxmedphys_wd_osu_list@lists.osu.edu</u></a></span><span style="font-family: Calibri, sans-serif; font-size: 11pt;"><br>
<b>Subject:</b> [Intl_DxMedPhys] Requirement for dose monitoring **EXTERNAL**</span></p>
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<span style="font-size: 1pt; color: white;">Hi all, I am trying to find in the current TJC standards any requirement for patient radiation dose monitoring for fluoroscopy. Am I missing it? Or is there a relevant non-TJC requirement? Our cath lab wants to opt
out of our dose monitoring</span></p>
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<span style="font-size: 1pt; color: white;">Hi all, I am trying to find in the current TJC standards any requirement for patient radiation dose monitoring for fluoroscopy. Am I missing it? Or is there a relevant non-TJC requirement? Our cath lab wants to opt
out of our dose monitoring</span></p>
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<span style="font-size: 12pt;">Hi all,</span></p>
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<span style="font-size: 12pt;">I am trying to find in the current TJC standards any requirement for patient radiation dose monitoring for fluoroscopy. Am I missing it? Or is there a relevant non-TJC requirement? Our cath lab wants to opt out of our dose monitoring
program, and I am looking for any accreditation-related reason why they can’t (our state regs do not require it).</span></p>
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<span style="font-family: Arial, sans-serif; font-size: 12pt; color: rgb(99, 144, 68);"><b>Stephanie M. Leon, PhD, DABR, DABSNM</b></span></p>
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<span style="font-family: Arial, sans-serif; font-size: 12pt; color: rgb(0, 102, 79);">Chief of Diagnostic Medical Physics</span></p>
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<span style="font-family: Arial, sans-serif; font-size: 12pt; color: rgb(0, 102, 79);">Associate Professor of Radiology</span></p>
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<span style="font-family: Arial, sans-serif; font-size: 12pt; color: rgb(0, 102, 79);">Tel (603) 650-3796<br>
</span><span style="font-family: Arial, sans-serif; font-size: 12pt; color: blue;"><a href="https://urldefense.com/v3/__http:/Dartmouth-Health.org__;!!NoSwA-eRAg!ADcCl68OJkbTYrpBcJWbdN0QvZLTKoxmyLXo7HFBGr6jJOOC8jno2gtBrDZVcr590IbKEZJ--nwqMSQ1Tk4F4Qsbsk-RFLnqnNlX6Q$" originalsrc="https://urldefense.com/v3/__http:/Dartmouth-Health.org__;!!NoSwA-eRAg!ADcCl68OJkbTYrpBcJWbdN0QvZLTKoxmyLXo7HFBGr6jJOOC8jno2gtBrDZVcr590IbKEZJ--nwqMSQ1Tk4F4Qsbsk-RFLnqnNlX6Q$" data-outlook-id="0582449c-5d66-414a-a8b1-f006be76a17e" style="color: blue; margin-top: 0px; margin-bottom: 0px;"><u>Dartmouth-Health.org</u></a></span></p>
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