DHS 157.82(4)(d)(d) If the medical physicist is not a full-time employee of the registrant, the operating procedures shall also specifically address how the medical physicist is to be contacted for problems or emergencies, as well as the specific actions to be taken until the medical physicist may be contacted.

DHS 157.82(5)(a)(a) A person who will be operating a therapeutic radiation machine for medical use shall be an American registry of radiologic technologists registered radiation therapy technologist or a user authorized under sub. (2) or (3). A person who is not an ARRT registered radiation therapy technologist shall submit evidence that he or she has satisfactorily completed a radiation therapy technologist training program that complies with the requirements of the joint review committee on education in radiologic technology.

DHS 157.82 NoteNote: “Essentials and Guidelines of an Accredited Educational Program for the Radiation Therapy Technologist”, Joint Review Committee on Education in Radiologic Technology, 1988, establishes the requirements for a therapy technologist training program. The document is available at: http://www.jrcert.org/.

DHS 157.82(5)(b)(b) The names and training of all personnel currently authorized to operate a therapeutic radiation machine shall be kept on file at the facility. Information on former operators shall be retained for a period of at least 3 years beyond the last date they were authorized to operate a therapeutic radiation machine at that facility.

DHS 157.82(5)(c)(c) A person who will be operating an electronic brachytherapy unit shall complete device specific instruction from the manufacturer or individual trained by the manufacturer, and training on procedures required by s. DHS 157.85 (16) (g) 4. and 5.

DHS 157.82(6)(6) Safety procedures. Written safety procedures and rules, including any restrictions required for the safe operation of the particular therapeutic radiation machine, shall be developed by a medical physicist and shall be available in the control area of a therapeutic radiation machine. The operator shall be able to demonstrate familiarity with these rules.

DHS 157.82(7)(7) Written directive required. Persons may not be exposed to the useful beam except for medical therapy purposes and unless exposure has been ordered in writing by a physician user qualified under sub. (2) or (3). This provision specifically prohibits deliberate exposure of an person for training, demonstration or other non-healing arts purposes.

DHS 157.82(8)(8) Information and records. The registrant shall maintain all of the following information in a separate file or package for each therapeutic radiation machine for inspection by the department:

DHS 157.82(8)(a)(a) Report of acceptance testing.

DHS 157.82(8)(b)(b) Records of all surveys, calibrations and periodic quality control checks of the therapeutic radiation machine, as well as the names of persons who performed those activities.

DHS 157.82(8)(c)(c) Records of maintenance or modifications performed on the therapeutic radiation machines, as well as the names of persons who performed these services.

DHS 157.82(8)(d)(d) Signature of each person authorizing the return of a therapeutic radiation machine to clinical use after service, repair or upgrade.

DHS 157.82(9)(9) Record retention. All records required by sub. (8) shall be retained for 3 years or until disposal is authorized by the department. Any required record generated prior to the last department inspection may be microfilmed or otherwise archived as long as a complete legible copy of the record may be retrieved.

DHS 157.82 HistoryHistory: CR 01-108: cr. Register July 2002 No. 559, eff. 8-1-02; CR 09-062: cr. (2) (c) and (5) (c), am. (6) Register April 2010 No. 652, eff. 5-1-10.

DHS 157.83(1)(1) Written policies. A registrant shall have written policies and procedures to ensure that radiation will be administered as directed by an authorized user. The policies shall meet all of the following specific objectives:

DHS 157.83(1)(a)(a) Prior to administration, a written directive is prepared for any external beam radiation therapy dose or electronic brachytherapy dose. A written revision to an existing written directive may be made prior to beginning treatment, or prior to delivery of a fractional dose, provided that the revision is dated and signed by an authorized user. If, because of the patient’s condition, a delay to provide a written revision to an existing written directive would jeopardize the patient’s health, an oral revision to an existing written directive shall be acceptable provided that the oral revision is documented immediately in the patient’s record and a revised written directive is signed by an authorized user within 24 hours of the oral revision.

DHS 157.83(1)(b)(b) Prior to the administration of each course of radiation treatments, the patient’s identity is verified, by more than one method, as the person named in the written directive.

DHS 157.83(1)(c)(c) External beam radiation therapy or electronic brachytherapy final plans of treatment and related calculations are according to the respective written directives.

DHS 157.83(1)(d)(d) Each administration is according to the written directive.

DHS 157.83(1)(e)(e) Any unintended deviation from the written directive is identified, documented, evaluated and appropriate action is taken.

DHS 157.83(2)(a)(a) Develop an operational procedures program that specifies staff duties and responsibilities, and equipment and procedures. The registrant shall implement the program upon issuance of a certificate of registration by the department.

DHS 157.83(2)(b)(b) Develop procedures for and conduct a review of the program including, since the last review, an evaluation of a representative sample of patient administrations and all medical events to verify compliance with all aspects of the operational procedures program.