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Fluoro Guidance

Preparing for a State Inspection


Fluoroscopic machines are inspected by the State every year in Hospitals and every other year in medical clinics. This information is designed to help you prepare for a State inspection.

Fluoroscopic machines include the Cath lab, C-arms, table fluoro, and mini c-arms.

Inspectors will review the following information:

  1. Operator’s qualifications:
    • RT’s are allowed to operate under a radiologist or a physician who has had training.
    • Physicians who have had proper training are called Non-Radiologist Practitioners
    • Physicians must have documentation that they have completed one of the State approved fluoro trainings.
    • Here is a list of approved fluoro training (pdf) for Non-Radiologist Practitioners
  2. Fluoro Policies:
    • Fluoro Radiation Safety
    • Set-up and operation instructions
    • Benchmark Policy (pdf)
    • Annual PPE check
  3. Fluoroscopic logs for each fluoroscopic unit:
    • Date of exam
    • Patient Name
    • Exam type
    • Machine settings
    • Fluoro operator
    • Fluoro On-time
  4. Annual physics survey:
    • Must be completed annually for each fluoroscopic machine
    • Completed by a licensed Health Physics Company
    • Patient entrance dose information determined
      • Patient entrance dose info must be posted on each fluoro machine
  5. Fluoroscopic benchmark times & review:
    • Must be completed annually (or more frequently) for each fluoroscopic machine
      • At least 2 routine adult procedures
      • At least 2 routine pediatric procedures
      • At least 2 ortho surgical procedures
      • At least 2 urologic surgical procedures
      • At least 2 angiographic procedures
      • At least 2 interventional cardiac studies
      • At least 2 angiographic procedures
    • Reviewed by the Radiation Safety Committee
      • If you do not have a RSC, the lead radiologist or physician should review the results.
    • Corrective actions are documented.
    • Fluoro Benchmark Guidance (pdf)

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