radiology services policies and proceduresuhsrn/pdf/combined_xray.pdf · all radiology equipment is...

Radiology Services

Policies and Procedures

November 2011

Table of Contents - Alphabetical

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Emergency Eye Wash Station

Inspection of Radiology Equipment

Maintenance of Radiology Equipment and radiographs

Operation of Radiology Equipment

Outgoing Film Identification for Transport

Patient Examination

Patient Identification

Patient Privacy

Patient Transportation

Patients Requesting release of Radiographs

Permanent Identification of Radiographs

Persons permitted in the Radiology Examination Room

Physician Request

Radiology Billing

Radiology Services at t University Health Services

Scope of Service

Signing out Radiographs

Transportation of Radiographs for interpretation

X-Ray Film Checkout

August 2011 Reviewed Approved by: ___________________________________ Director, University Health Services

___________________________________ Clinical Services Administrator

___________________________________ X-Ray Technologist SUBJECT: EMERGENCY EYE WASH STATION CHECK POLICY It is an OSHA requirement that the Emergency Eye Wash Station be tested weekly. PROCEDURE Remove caps from eye pieces, pull lever out to allow for the water to flow through and turn on the faucet. Check for proper flow of water from the station. Check station for build-up of lime and residue. If a problem should exist with the station, note it on the log in sheet and notify the Clinical Services

Administrator. Document the date eye wash station check was performed on log in the dark room. Annual Review

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March 2011

Revised Approved by: ______________________________________ Office of Student Affairs ______________________________________ Director, University Health Services ______________________________________ Medical Director

SUBJECT: INSPECTION OF RADIOLOGY EQUIPMENT POLICY: All radiology equipment is inspected annually by a state licensed Physicist as required by law. The radiology department adheres to all codes and regulations. PURPOSE: 1. All safety warnings are posted in highly visible areas. 2. Radiation monitor badge is worn by radiology department personnel during the work Day. 3. Protective lead aprons are used in all exams, whenever possible. GUIDELINES:

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SUBJECT: MAINTENANCE OF RADIOLOGY EQUIPMENT AND RADIOGRAPHS POLICY: All radiology equipment is maintained and inspected in accordance with Indiana State and Federal guidelines. PROCEDURE: 1: The film processor is maintained on a monthly cycle by a contracted licensed company, Berrien X-Ray. 2: All exposed film is kept in the required leaded bin. 3: Exposed films are maintained in a patient’s film jacket for seven years, and are then discarded through the recycle process of radiographs. 4: Safety lights in the dark room are maintained at the designated power to avoid overexposure of radiographs during processing. 5: Film cassettes are maintained and cleaned on a weekly basis to avoid artifacts on any radiographs. Annual Review

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OPERATION OF RADIOLOGY EQUIPMENT: POLICY: All equipment controlled by the Radiology Department is to be operated by licensed Radiographers with specific training in Radiologic Technology. These persons are subject to the rules and regulations of the State and Federal regulatory bodies. Interpretations of all radiographic examinations are made by a radiologist. Annual Review

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March 2011 Revised Approved by: ______________________________________ Office of Student Affairs ______________________________________ Director, University Health Services ______________________________________ Medical Director

SUBJECT: OUTGOING FILM IDENTIFICATION FOR TRANSPORT POLICY All outgoing films must have appropriate identification and labeling, including destination instructions, and must be placed in the identified film holder marked “outgoing films.” GUIDELINES A. Physician Referral of Patient.

1. When a patient is referred to an outside physician or facility, the front office staff member assisting with scheduling will ask the patient if he/she has had an x-ray film taken.

2. The patient’s name, date of birth, where the x-ray was administered, the outside facility or the name of the referred provider, date of scheduled appointment and mode of transport must be provided to the x-ray technologist directly or through voice mail.

3. If the x-ray technologist is not available the front office will sign out the requested films and reports by following the “check out film” policy and “ID and Handling of Outgoing Films.”

B. Patient Transport

1. Any film prepared for patient transport must be identified as a patient film pick up with the patient’s name clearly identified on the film travel envelope. A sign out sheet will be attached to the film envelope. This must be filled out before the x-ray is released to the patient. This release form will be returned to the x-ray office or

OUTGOING FILM IDENTIFICATION FOR TRANSPORT placed in the “incoming x-ray box.”

2. If the x-ray technologist is on duty, the film will be prepared, release filled out and film handed directly to the patient.

3. If the x-ray technologist is not present at the time of request, a voice mail message on the x-ray office phone line is to be left with the patient’s name and date of pick up.

4. If the x-ray technologist is not available at time of the request for immediate access, the check-out film policy with release of x-ray form must be followed before the x-ray film is released.

Courier Transport

All films transported by van or security personnel must have the patient’s name, date of transport, and film destination on the travel envelope.

Physician Referral of Patient

When a patient is referred to an outside physician or facility, the front office staff member assisting with scheduling will ask the student if he/she has had x-ray films taken, the patient’s name, date of birth, where the x-ray was administered.

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March 2011

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SUBJECT: PATIENT EXAMINATION POLICY: Patients will receive a radiographic examination performed by and under the service of a certified and licensed Radiographer. GUIDELINES: 1: Patient will be identified by with the Radiology Request Form. 2: Each female patient will be asked if there is any possibility that she could be pregnant; this response is documented on the form. 3: The patient is appropriately prepared by removing clothing, jewelry, and/or other articles from the body that may obstruct the radiographic image, and is shielded for the procedure whenever possible. 4: Upon completion of the radiographic examination, the patient returns to the physician at University Health Services who will provide an initial review of the films and discuss his/her interpretation with the patient. 5: The patient will be released as advised by the physician. 6: The radiographic film studies will be delivered to SJRMC (XRC) or Radiology, Inc. where a radiologist will interpret the study. Any abnormal findings will be phoned to the UHS physician. 7: The radiologist’s interpretation will be faxed to University Health Services within 24 hours of delivery to

PATIENT EXAMINATION the radiology facility. 8: The University Health Services physician will contact the patient, should follow up be required. Annual Review

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March 2011


SUBJECT: PATIENT IDENTIFICATION POLICY: Patient identification will be verified before a radiographic examination. The Radiographer is responsible for correctly identifying the patient to be examined. Each patient order will accompany them to the Radiology Department, and the Radiographer is to check the order to verify the ordered examination. A Notre Dame ID may be requested for identification purposes. GUIDELINES: 1: Introduce yourself to the patient by name. 2: Prior to the examination, the Radiographer verifies the patient’s name. 3: Before taking the radiographs, it is important to inform the patient of the procedure and answer any questions relating to the radiographic examination being performed. 4: Provide discharge information after determining the quality of the radiographic study.

PATIENT IDENTIFICATION Annual Review

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SUBJECT: PATIENT PRIVACY POLICY: Respect for privacy during a patient exam will be ensured. GUIDELINES:

1. Patients will be provided a private place for the radiographic exam. 2. The door to the examination room shall be kept closed during the radiographic examination.

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SUBJECT: PATIENT TRANSPORTATION POLICY: If a patient should be in need of transport for any Radiological exam, the Health Services van or security escort will be provided to take a stable patient to an off-campus Radiology facility at no additional cost to the patient. Annual Review

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SUBJECT: PATIENTS REQUESTING RELEASE OF RADIOGRAPHS POLICY: Patients requesting radiographs to be taken out of the facility are required to complete the ‘Release of X-Ray’ form (See examples) Original copies of these forms are to be kept with the patient’s film jacket. See Check Out Policy. Follow Check Out Policy. Annual Review

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Revised Approved by: ______________________________________ Office of Student Affairs ______________________________________ Director, University Health Services ______________________________________ Medical Director _____________________________________________________________________________________ SUBJECT: PERMANENT IDENTIFICATION OF THE RADIOGRAPHS POLICY: The Radiographer is to produce a properly identified radiograph. PROCEDURE: 1: Side Markers:

- All radiographs are to have a right or left marker on the film prior to processing. - Writing the side marker on the film after exposure will not constitute an accepted standard.

2: Each film will be identified by the attached requisition and permanently stamped with the following information:

- Patient name - Date of Birth - Date of exam - Procedure location

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SUBJECT: PERSONS PERMITTED IN THE RADIOLOGY EXAMINATION ROOM POLICY: Only under the discretion of the Radiographer will a person other than the patient be allowed in the examination room. GUIDELINES: 1: The Radiographer shall direct that any person other than the patient involved in the radiographic procedure be excluded from the same room during the exposure, except:

- In the judgment of the Radiographer or the physician, a person related to the patient should be present to assist in the emotional support and/or the safe handling of the patient. For such exceptions, the related person shall not be a pregnant woman. The Radiographer asks such a related person if they are/could be pregnant. If there is any possibility the person is pregnant, then she will be excluded for the room during the exposure.3

2: The Radiographer shall require related persons to wear a protective lead apron, lead gloves, and/or thyroid collars if the procedure requires such protection during the exposure. Annual Review

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March 2011

Issued,Reviewed,Revised Approved by: ______________________________________ Office of Student Affairs ______________________________________ Director, University Health Services ______________________________________ Medical Director

SUBJECT: PHYSICIAN REQUEST POLICY: University Health Services Radiology Department requires a “reason for exam” (ordering diagnosis) on all requisitions. PROCEDURE: 1: Complete the required information on the patient‟s encounter form in the designated radiology section.

- Procedure - Ordering diagnosis for the procedure

2: Patient or accompanying staff member will provide the Radiographer with the patient‟s encounter form. The Radiographer will complete the „Radiology Request‟ form.

- Procedure - Date of Service (DOS) - Date of Birth (DOB) - Signs and symptoms

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SUBJECT: RADIOLOGY BILLING POLICY: All radiographic studies performed at University Health Services will generate a charge. Radiologist interpretation fee will be billed separately. GUIDELINES:

1. Radiographic studies performed at University Health Services will be charged to the student’s account or Risk Management as appropriate. 2. Radiologist interpretation fee will be billed directly to the patient’s insurance company, if an insurance card is available to be copied or responsible party.

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March 2011


SUBJECT: RADIOLOGY SERVICES AT UNIVERSITY HEALTH SERVICES POLICY: The University of Notre Dame will provide limited on-site diagnostic imaging. The

radiographic equipment located on the first floor of Saint Liam Hall is in service for the academic year only. The Radiographer is here Monday-Friday, 10:00AM-4:30PM. When the radiology service is not available, or the schedule is too full, patients will be sent to the appropriate off campus facility for the diagnostic imaging examination.

PURPOSE: 1: To provide limited diagnostic imaging capabilities 2: To assist the professional staff in efficient diagnosing of injuries and/or illness 3: To provide convenience for the clients of University Health Services GUIDELINES: 1: Radiographic equipment is located on the first floor of Saint Liam Hall and is in service for the academic year only. 2: Hours of service are 10:00AM-4:30PM, Monday through Friday. When the radiology service is not

RADIOLOGY SERVICES AT UNIVERSITY HEALTH SERVICES available, or the schedule is too full, patients will be sent to the appropriate off-campus facility for the diagnostic imaging examination. 3: Voicemail is available in the Radiographer’s office for student of professional requests for radiographs or reports. 4: In emergency situations when the Radiographer is not available, staff will check out radiographs according to policy. PROTOCOL: 1: The Radiographer will receive written orders from a physician or from the registered nurse when approved by a University Health physician. 2: The patient is directed to the Radiology Department by the registered nurse where the Radiographer registers the patient. 3: The patient is appropriately prepared by removing clothing, jewelry, and/or other articles from the body that may obstruct the radiographic image, and is shielded for the procedure whenever possible. 4: Upon completion of the radiographic study, the patient is directed to the physician at the Health Center who will provide the initial review of the radiograph and discuss his/her interpretation with the patient. 5: The radiographic exam will then be delivered by courier to a radiologist, who will interpret the radiograph. 6: The radiologist’s interpretation will then be faxed to the University Health Services Radiology Department. 7: A copy of the radiologist’s interpretation is placed in the patient’s medical record and provided to the University Health physician for review and signature. A copy of the report will be filed in the patient’s film jacket. RADIOGRAPH RELEASE PROCEDURES: A patient’s original radiographs may be loaned out for referrals if they are to be returned. Duplicates must be made if the referring physician requires a copy for his files. Other diagnostic procedures require duplicating for out-of-state referrals (i.e. CT, NM, US) 1: The patient is identified by name, date of radiographic study and birth date. Film jackets are filed alphabetically in the radiology examination room. Remove the requested film study from the original jacket. Write the date, destination, and the radiographic exam (finger, hand, foot, etc.) to be signed out on the front of the original film jacket. 2: A ‘Request for Release of Medical Records’ form and a ‘Radiology Film Release’ form must be completed, signed and placed in the original jacket. The jacket should then be refilled in the radiology examination room.

RADIOLOGY SERVICES AT UNIVERSITY HEALTH SERVICES 3: The radiographs and the radiologist’s interpretation, as well as a copy of a ‘Loan Letter’ (see example) should be mailed in a film jacket mailer. The patient’s name should be written on the outside of the envelope. 4: If the patient is transporting the radiographic study, the patient is informed that the radiographs are original records and must be returned to University Health Services by the patient or the physician to whom the radiographic study was loaned. A ‘Radiology Film Release’ form is to be filled out by the patient requesting the film study and placed in the patient’s original film jacket. MISCELLANEOUS: Any charges generated for radiological services at Saint Liam Hall will be billed directly to the student’s account. Charges for interpretation of radiographic studies by the radiologist will be billed to the student or responsible party by the off-campus radiology facility. Annual Review

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SUBJECT: SCOPE OF SERVICE POLICY: It is the role of University Health Services Radiology Department to provide diagnostic imaging service to all currently enrolled students and worker’ compensation cases, as ordered. PURPOSE: In the event of a needed Radiographic studies when the radiologic technologist is not available, arrangements will be made to take the patient to the nearest outside facility, at no additional cost to the patient. UHS van or security transport may be used, if

available. GUIDELINES: 1. All radiographic examinations require a signed Radiology Order Form from an attending Physician or a licensed Registered Nurse who has received the verbal order. 2. The Radiographic studies will be interpreted by a licensed Radiologist within a 24 hour period. Annual Review

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SUBJECT: SIGNING OUT RADIOGRAPHS POLICY: Any radiographs that are removed from a patient’s permanent film jacket must be signed out with the proper documentation according to the Check Out Procedure. PROCEDURE: 1: Remove requested radiographs from the permanent file envelope and place the radiographs in a travel envelope. (Film copies to be made upon request). 2: Make a copy of the radiologist’s interpretation and place the copy into the travel envelope. The original report remains in the permanent film jacket. 3: Complete the Sign Out Sheet with the patient’s name, date of release, destination of films and signature of the individual checking out the radiographs. Sign Out Sheets are located in the Radiology Office. 4: Have the patient complete the ‘Release of X-Ray’ form and file this in the individual’s permanent film jacket. GUIDELINES: NEVER give the permanent film jacket to the patient or use it for transport for purposes outside University Health Services.

SIGNING OUT RADIOGRAPHS Annual Review

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,Revised

Approved by: ______________________________________ Office of Student Affairs ______________________________________ Director, University Health Services ______________________________________ Medical Director

POLICY: TRANSPORTATION OF RADIOGRAPHS FOR INTERPRETATION PROCEDURE: 1: All radiographs will be transported to a radiologist by courier at the end of each day. 2: All radiographs must be signed out on the X-Ray Transfer Form (see sample). The yellow copy will accompany the imaging studies while the white copy remains in the Radiology Department. 3: Radiographs will be returned to University Health Services within 2 business days. A copy of the radiologist’s interpretation is placed in the patient’s film jacket. Annual Review

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March 2011 Revised Approved by: ___________________________________ Director, University Health Services

___________________________________ Assistant Director, Clinical Services

___________________________________ X-Ray Technologist SUBJECT: X-RAY FILM CHECK OUT POLICY Any x-ray film that is removed from a patient’s permanent x-ray file must be signed out with proper documentation according to the check out procedure. PROCEDURE

1. Remove requested x-ray film from the permanent file envelope and place the film in a travel envelope. (Film copies to be made upon request.)

2. Make a copy of the radiology report and place the copy into travel envelope. The original report remains in the permanent x-ray file.

3. Complete the Sign Out Sheet with patient name, date, destination of films and signature of individual checking out the films. Sign out sheet is located in the x-ray office.

4. Have the patient complete the “Release of X-Ray” form and file this in the individual’s permanent x-ray file envelope.

GUIDELINES NEVER give the permanent x-ray file envelope to the patient or use it for transport for purposes outside University Health Services.

X-RAY FILM CHECK OUT Annual Review

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