Radiology Procedure Manual-Sampls
Radiology Procedure Manual-Sampls
Radiology Procedure Manual-Sampls
Date Created :
Radiology
15-01-2008
Chief Medical Superintendent
Approved By :
Name
Signature :
Medical Superintendent
Reviewed By :
Name :
Signature :
Director
Issued By :
Name :
Signature :
Head of the Department-Radiology
Responsibility of Updating :
Name :
Signature :
Page of Contents
Sl.Order Particulars
A
Purpose
Scope
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Abbreviations
Departmental Procedures
Registration Certificates
Acts
Quality Control
Maintenance of Equipment
Quality Plan
A. Introduction:
Radiology is the medical specialty directing medical imaging technologies to diagnose and
sometimes treat diseases. Originally it was the aspect of medical science dealing with the medical
use of electromagnetic energy emitted by X-ray machines or other such radiation devices for the
purpose of obtaining visual information as part of medical imaging. Radiology that involves use of
x-ray is called roentgenology. Today, following extensive training, radiologists direct an array of
imaging technologies (such as ultrasound, computed tomography (CT) and magnetic resonance
imaging) to diagnose or treat disease.
B. Purpose and Scope :
1. The Department of Radiology of the hospital provides comprehensive services in the following
imaging technologies ( a brief description of the same are also stated below) :
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i.
ii.
iii.
iv.
General Radiography: X-rays are a form of radiation, like light or radio waves that can be
focused into a beam. Once it is carefully aimed at the part of the body being examined,
an x-ray machine produces a small burst of radiation that passes through the body,
recording an image on photographic film or a special image recording plate
Mobile Radiography: Mobile unit used to X-ray bed ridden patients and sometimes used
to X-ray during operative procedures in Operating Room.
Ultrasound : Ultrasound, or sonography, uses high frequency sound waves to see
inside the body. As the sound waves pass through the body, echoes are produced, and
bounce back to the transducer. These echoes can help doctors determine the location of
a structure or abnormality, as well as information about its make up. Ultrasound is a
painless way to examine internal organs.
Magnetic Resonance Imaging (MRI) : M R scans use magnetic resonance that images
the body from different angles and then use computer processing to show a cross
section of the various tissues and organs pictured .MRI scans have proven to be very
help in diagnosis of soft tissues especially brain , spinal cord , joints, abdomen ,chest
and other muscles.
General X-Ray
Special X-Ray such as HSG
Ultra Sonography
Magnetic Resonance Infraction
C. Abbreviation:
1. IP
= Inpatient
2. OP
= Outpatient
= Ultrasound
= Operating Room
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E.Departmental Procedures
i. Out Patient with Consultation:
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No
Yes
Does the
invstgn need
preparation?
Yes
No
Yes
Can the
pt. be
allocated
for
invstgn?
No
Pt. is told abt the requirement
of appt. & given for the earliest
available time
ii. In patients
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Nurse will be
informed the
time of
invstgn
No
Yes
Is pt. pprtn
needed?
Inform the nurse about the
preparation
No
If Pt. is
prepared?
Yes
The nurse is told to send the pt. to
the dept with patients case sheet.
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Invstgn is done and order entry
Dispatching Wet
films
Out-patients
No
Yes
Is the films
processed
?
Is the pt.
is inpatient?
Yes
iv.In-patients / Emergency patients (For all Radiology Procedures) After Duty Hours
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Is the pt.
preparatio
n needed?
Yes
No
Check with the nurse whether the pt. is
prepared or not
pt. is prepared
v.
Radiology procedures
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Yes
Is the Pt.
Inpatient?
Yes
Is
preparation
adequate?
No
No
Yes
Guide the Pt. and wait till the Pt. is
prepared. Then take the Pt. for
invstgn only once when the
preparation completes
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No
Yes
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No
Yes
Is the Pt.
having full
bladder?
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No
Yes
Is the Pt.s
bladder
empty?
x. Report Generation:
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No
Yes
Is there any
corrections?
MRI Scanning
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Need for MRI prescribed by the Doctor. MRI requisition form filled by the treating
consultant clearly indicating the part and compatibility status.
No
Details mentioned in
the requisition form
entered in the MRI
register
Yes
Does the
patient need
preparation?
Patient is informed
about the preparation
to be taken. Time and
date for next
appointment is fixed.
Patient is instructed
to remove any
metallic articles and
change
Patientthe
is gown
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3. The hospitals Radiology Department have a valid and current Radiology AERB
Registration & Valid Approvals issued by the District Health & Family Welfare Office,
Uttar Pradesh department, which will be posted in public view.
4. All staffs will be provided with Thermo luminescent Dosimeter to measure (Radiation
received during working hours) Occupational exposure
5. All required records will be maintained by the Radiology Department.
G . Registration certificates:
i.
The below Mentioned Diagnosis (Critical Reports) will be informed to the treating
consultant immediately after the procedure:
i. Ectopic Pregnancy
ii. Deep Vein Thrombosis
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iii. Perforation
iv. Incomplete Abortion
v. Hemorrhage
vi. Infarct
vii. Fracture.
viii. Pneumothorax
ix. Obstruction
x. Vascular Injury
The Department of Radiology follows the following statutory guidelines for registration of the
Ultrasound scans machine for Antenatal scan:
1. Ultrasound Machine Purchased will be registered with Uttar Pradesh Health Department.
2. Form B will be issued by the health department after registration.
3. A Registration number will be allotted to the radiology department in form B.
4. Statutory requirements are as follows:
a. Form B should be displayed in the ultrasound scan room.
b. Posters from the Health department (in local language) should be displayed in the
ultrasound scan room. Contents of the display are as follows:
i. Sex determination is ILLEGAL board should be displayed in English & local
language in OPD and in the department.
c.
Scanned Patient details should be preserved for 2 years from the date of Scan.
Total number of Antenatal Scans done should be sent to the following every month
on or before 5th through Register post to the District Health officer .
g. Xerox copy of the same should be filed and preserved in the department.
J. Quality Control: The main objective of quality control is to enhance the quality of x-ray/results by
checking the precision, accuracy and consistency of tests done.
Validation of examination procedure technically and clinically will be done by qualified and well
trained radiologist.
Quality Assurance is done with the following monitoring
a. Tracking Turn around time and waiting times
i.
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ii.
Positioning
Artifacts.
Exposure factors
ii.
Grading - scores
c.
The Quality Assurance Manual of the department ( Ref N0 RML/QAM/01 ) can be referred for further
details.
Confidentiality of Reports : Confidentiality of patients and their test reports are ensured through the
following :
1. In the course of Performing work responsibilities all information with regard to patient, their
family, their physician and / or the hospital is kept confidential.
2. All the staff of the department are cautioned not to discuss any such information with others.
3. Personnel are expected and ensured to conduct themselves with professional dignity at all
times.
4. Radiologist are the only persons authorized to inform reports to the doctors.
K. Patient Education and Safety :
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a. All patients are welcomed and explained about the process of the diagnostic
investigation in detail before starting the process.
b. All Patient are explained when and how their reports can be collected.
c.
g. All necessary steps will be taken to reduce /minimize /eliminate discomfort /pain
while conducting the Investigation.
h. In the course of performing work responsibilities all information with regard to
patient, their family, their physician and / or the hospital is kept confidential. The staff
of the department are cautioned not to discuss any such information with others.
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before 10 :00am
f. All critical reports are verbally informed to the concerned consultant immediately by
the Radiologist.
g. In case of any unavoidable delay, patients are kept informed for the reason for the
delay and by what time the investigations/delivery of reports are likely to be completed.
h. Any patient query regarding the reports will be dealt with immediately and clearly
explained, and further consultation arranged.
i. No test results are given to Patient verbally or over telephone .
j. Patient Reports are to be treated as completely confidential.
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MRI scan:
1. Reports of all MRI scans done for OP will be dispatched next day morning
before 10:00 hrs in the morning.
2. Reports of MRI scan done for IP before 1300 hrs will be dispatched to the
respective inpatient wings prior to 1500 hrs on the same day .Reports of MRI scans
done for IP after 1300 hrs will be dispatched to the respective inpatient wings next
day morning before 10 :00am.
d. Reporting of Emergency Cases:
1. In case of an emergency report, the radiologist will see the film and give a verbal
report to the referring consultant by phone.
2 . If the patient is referred or wants to go to some other hospital (on request or against
medical advice), Reports will be generated within 30 minutes (provided it is during
Radiologists office hours & if there is no emergency ultra sound scanning).
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i.
ii.
According to the number of patients available on that particular day for the
iii.
investigation.
iv.
v.
vi.
vii.
Please note that even in case of given appointments patients from the critical care areas of
the hospital like the Emergency Department ,OT and other patients requiring emergency
imaging investigation etc are given priority for all procedures.
O. Maintenance of Equipment:
1. Guideline Instructions : General
a. All staff will clean the Machine in their Posted unit. Staff will conduct daily check on its
working condition daily & do regular warm up. Shutdown of machine should be done
after working hours.
b. Night Shift person is responsible for the machine till the handover to the next day
Morning shift person.
c.
In case of continuous power fluctuation shut down all the Machines, till proper power
supply is observed.
g. In daily Briefing Working condition & Breakdowns of machine should be handed over
without fail.
2. Infection control:
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b. Machines should be cleaned with Antiseptic Solution after handling Road Traffic
Accident & Infectious patients.
c.
Mobile Machines shifted to Operating room and Intensive care units, wheels & area
in contact with patients should be cleaned with disinfectant solution before and after
use of the machine.
3. Breakdown management:
a. During breakdowns shutdown and restart the unit, check all Input & cables for loose
connections. In case this fails, complaint should be logged into Instrument History
Card and Work order should be raised and given to the Biomedical In charge
mentioning the Machine Name, time of breakdown.
b. The Biomedical engineer will inspect the machine & take necessary action as per
their protocol.
c.
It is the duty of the Radiographer to inform the Head of the Department of Radiology,
Registration Counter ,ED , ICCU and other patient care areas the breakdown time
and follow up on rectification till its working time every 12 Hours the status of the
breakdown .
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P.
The training of Departmental Staff : The training of staff (for both existing and new staff) is
of utmost importance to prepare professionals who have high specific knowledge in their
area and who could give the best quality of care to their patients. Therefore training in
Radiology is a very complex and difficult task mainly due to wide spectrum of radiological
applications in the total care process and variety of imaging modalities .Hence the
department lays special emphasis on training of the employees to acquaint them with the
knowledge and skill pertaining to their job. The approach to training of the staff adopted by
the department is as follows:
a. One week department Induction for every new employee (Transferred or Fresh
Recruit) joining the department.
b. One week department Induction to learn department policy & procedures and safety
training will be conducted for the new employee in the department.
c. Training in Safety procedures to follow if equipment malfunction occur.
d. Training relating to the operation of any new equipment is given prior to the usage of
the equipment by company engineers to ensure its proper and safe handling.
e. All professional personnel are expected to be competent and proficient in all
performance of all procedures by the end of the training program.
f.
The training program will serve as verification of initial personnel competency and
ability to satisfactorily perform patient care and services.
g. Those areas felt to be requiring additional focus by the trainee will be identified as
personal goals, for which improved performance will be emphasized.
h. All staffs should attend and do regular training.
Departmental Orientation programme for the new employees (Fresh recruit or transferred
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g. Turn Around time for different types of cases ( Normal , Urgent etc).
h. Safety procedure and Policy of the department.
i.
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IP
DATE
XR-FILM
USG
ECHO
MRI
Total procedures
Total patients
OP
DATE
XR-FILM
USG
ECHO
MRI
Total Procedures
Total patients
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Lohiya Hospital
RADIOLOGY
DEPARTMENT
MONTHLY
STATISTICS
TOTAL
MONTH
T.
X-RAY
No. of xrays/technician/day
USG
No. of MRI
scans per
day
USG per
day
QUALITY PLAN
Quality Indicator:
a. Indicator : Turn around time for reports
Date
X-ray
No.
Pt. Name
MRN
Procedure Done
Received
request
time
Patient taken
for
procedure
Duration
In Minutes
b. Benchmark:
i.
j.
Form
Request Form with consent for procedures
F & G consent form for OBG ultrasound
k. Registers
S No:
1
2
3
Form
Daily entry registers for all procedures
Outsourcing register
Pharmacy consumable register
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