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Creating and maintaining records and reports are essential components of the professional practice of registrants. Registrants' records and reports provide information to other health care professionals about relevant aspects of patient care, treatment, and assessment.
Registrants must be proficient in creating records, charts, incident and other reports that attest to the diagnostic, treatment, quality assurance, workplace and patient safety procedures that have been carried out. Registrants must have the knowledge, skills and judgement to record information that will adequately identify the subjects of all the images and data they create and treatments they administer. Registrants must produce records and reports that are accurate, complete, legible and timely.
Registrants must:
a. record results of quality control tests
b. record and report any equipment faults or problems
c. record and notify the patient’s physician, authorized health professional, radiologist, nuclear medicine physician, cardiologist or radiation oncologist of any allergies, abnormal test results, pregnancy or other contraindications to the ordered procedure
d. mark all images and data with the patient’s identity
e. ensure all images and data are archived according to principles and guidelines established by the employment facility
f. record the patient’s reactions to the treatment or procedure or any administered substances
g. record all pertinent aspects of patient care and all procedures performed, including emergency treatments and descriptions of, and reasons for, any deviations from standard procedures on order forms, treatment prescriptions, patient health records or other relevant documentation
h. forward patients’ records, images and pertinent data to appropriate recipients
i. record and inform the patient and/or members of the health care team of any follow-up care required
In addition, registrants in the specialty of nuclear medicine and radiation therapy must:
j. record results of radiopharmaceutical assays, quality control and other tests, radioactive preparations and disposal methods of radioactive materials
In addition, registrants in the specialty of nuclear medicine must:
k. record receipt and disposal of radiopharmaceuticals, generators and radioactive materials
l. label radiopharmaceutical preparations
m. maintain radiopharmaceutical and pharmaceutical dispensing records
In addition, registrants in the specialty of radiation therapy must:
n. record and communicate any concerns regarding the treatment or treatment prescription to the appropriate radiation oncology personnel
In addition, registrants in the specialty of diagnostic medical sonography must:
o. record and communicate their observations and technical impressions regarding the diagnostic ultrasound procedure to the reporting health professional