[Intl_DxMedPhys] TJC Fluoro skin dose standards

[Daniel Vergara]

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) cases in which a skin burn occurs AND
resulted from inappropriate use of fluoroscopy.

Daniel

On Thu, Apr 16, 2026 at 6:22 AM Shuman, Jill via Intl_dxmedphys_wd_osu_list
<intl_dxmedphys_wd_osu_list at lists.osu.edu> wrote:

> 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
>
> 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
>
> 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?
>
>
>
> More notes below for those curious.
>
>
>
>
>
> From the hospital crosswalk document:
>
>
>
> 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.
>
>
>
> The only place left in the survey process guide asking for fluoroscopy
> dose states:
>
> *Reports, including medical record number, documenting fluoroscopy
> radiation dose for 5 recent inpatients. RC.12.1.1 EP 2 *
>
>
>
> RC.12.1.1 EP 2:
>
> The medical record contains the following clinical information:
> - Admitting diagnosis
> - Any emergency care, treatment, and services provided to the patient
> before their arrival
> - Any allergies to food and medications
> - Any findings of assessments and reassessments
> - Results of all consultative evaluations of the patient and findings by
> clinical and other staff involved in the care of the patient
> - Treatment goals, plan of care, and revisions to the plan of care
> - Documentation of complications, health care–acquired infections, and
> adverse reactions to drugs and anesthesia
> - All practitioners' orders
> - Nursing notes, reports of treatment, laboratory reports, vital signs,
> and other information necessary to monitor the patient's condition
> - Medication records, including the strength, dose, route, date and time
> of administration, access site for medication, administration devices used,
> and rate of administration
> 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.
> - Administration of each self-administered medication, as reported by the
> patient (or the patient’s caregiver or support person where appropriate)
> - *Records of radiology and nuclear medicine services, including signed
> interpretation reports*
> - All care, treatment, and services provided to the patient
> - Patient’s response to care, treatment, and services
> - Medical history and physical examination, including any conclusions or
> impressions drawn from the information
> - Discharge plan and discharge planning evaluation
> - Discharge summary with outcome of hospitalization, disposition of case,
> and provisions for follow-up care, including any medications dispensed or
> prescribed on discharge
> - Any diagnoses or conditions established during the patient’s course of
> care, treatment, and services
> Note: Medical records are completed within 30 days following discharge,
> including final diagnosis.
>
>
>
>
>
> 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).
>
>
>
> 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).
>
>
>
> Thanks,
>
> Jill
>
>
>
>
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-- 
Daniel Vergara
xvergarax at gmail.com
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