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SOP for Radiology

Ist Edition: August; 2016
Quality Assurance Cell
Delhi State Health Mission
Department of Health and Family Welfare
Government of NCT of Delhi

Compilation facilitated by : State QA Cell (Nodal Officer: Dr. Monika Rana , Consultant :
Ramesh Pandey , Communitization Officer : Arvind Mishra , Statistical Officer : Shahadat
Hussain ), ARC ( Maneesh and Md. Irshad Ansari).
Designed and Formatted by: Graphic Designer : Mansi Rana

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 This document has been prepared by the Expert Committee comprising of:

Sr. Designation
Name
No.
Dr. Anju Garg Director Professor & HOD
(Radiodiagnosis), Lok Nayak
1. Hospital & Maulana Azad Medical Chairperson
College

Dr. Poonam Narang Director Professor (Radiodiagnosis),

Govind Ballabh Pant Institute of
2. Post Graduate Medical Education Member
&Hospital

Dr. L R Richhele Consultant (Radiodiagnosis) & HOD,

3. Deen Dayal Upadhyae Hospital Member

Dr. Rashmi Dixit Director Professor (Radiodiagnosis),

Lok Nayak Hospital & Maulana Azad
4. Member
Medical College

The SOPs have been prepared by a Committee of Experts and are being circulated for
customization and adoption by all hospitals. These are by no means exhaustive or prescriptive. An
effort has been made to document all dimensions / working aspects of common processes /
procedures being implemented in provision of healthcare in different departments. This document
pertains to Radiolgy. The individual hospital departments may customize / adapt / adopt the SOPs
relevant to their settings and resources. The customized final SOPs prepared by the respective
Departments must be approved by the Medical Director / Medical Superintendent and issued by
the Head of the concerned department. HOD shall ensure that all stakeholders are trained and
familiarized with the SOPs and the existing relevant technical guidelines / STGs / Manuals
mentioned in the SOPs are made available to the stakeholders.

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DETAILS OF THE DOCUMENT

-------------------------HOSPITAL

Address:
________________________________________________

Document Name:

Document No.:

No. of Pages:

Date Created:

Designation :

Prepared By: Name :

Signature:

Designation :

Approved By: Name :

Signature:

Designation :

Responsibility of Updating: Name :

Signature:

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 INDEX

S. No. Title Pages

1 Radiology 8-23

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 AMENDMENTSHEET

S.N Pagen Date of Details of Reaso Signatureof Signatureoftheappro

o. o. amendme theamendme ns thereviewi val authority
nt nt ng
authority

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 CONTROL OF THE DOCUMENT

The holder of the copy of this manual is responsible for maintaining it in good and safe condition
and in a readily identifiable and retrievable form.

The holder of the copy of this manual shall maintain it in current status by inserting latest
amendments as and when the amended versions are received.

The Manual is reviewed atleast once a year (or in between SOS if so required) and is updated as
relevant to the Hospital policies and procedures.

The Authority over control of this manual is as follow:

Prepared By Approved By Issued By

Quality – Nodal Officer

Name: Medical Superintendent

Designation : HOD /Dept. In charge Name: Name:

Signature: Signature: Signature:

The Original Procedure Manual with Signatures on the Title page is considered as ”Master Copy”,
and the photocopies of the master copy for the distribution are considered as “Controlled Copy”.

Distribution List of the Manual

Sr. No. Officials Signature of Officials receiving copy

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Radiology GNCTD/………………../SOP/RAD/08

SOP for Radiology

Objective:

To ensure consistently safe, effective, efficient, appropriate, & timely imaging diagnostic services
to each patient visiting the hospital.

Purpose: Smooth running of radiology department to ensure uninterrupted patient service

Scope : Entire radiology department

Sl. Activity/Description Responsibility Ref

No. Doc/
Record
1. Statutory compliance
1.1 HOD & RSO shall be responsible for compliance to RSO & PNDT In charge
AERB registration pertaining to equipment using X
rays in the department
a) eLORA registration/licensing of the
institution/department, RSO & all equipment
shall be done & maintained
b) Periodic QA of equipments& premises (as per
AERB guidelines) will be done through the
AMC/CMC provider and submitted to AERB.
c) Radiation workers will be identified & TLD
badge monitoring shall be done for them as per
AERB guidelines.
d) Periodic health check including blood cell count
& general physical examination shall be
conducted & recorded for all radiation workers
as per AERB guidelines.
e) Availability, maintenance, QA of all radiation
barriers (lead aprons, goggles, gonadal shields,
lead curtains)
f) Education, training & monitoring regarding
radiation safety practices shall be done by RSO. Deptt. Head/Hospital RSO
g) These activities will extend to Cath Labs, DSA
labs, C arms in OT etc.
1.2 HoD & PNDT Nodal Officers shall be responsible for HoD & PNDT Nodal Officer
compliance to PCPNDT regulations pertaining to
US/ECHO/Doppler as well as CT & MRI equipment in
the in the department.
a) PCPNDT registration of the

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institute/department/ equipment & personnel

handling these equipment shall be done &
maintained.
b) Daily & monthly reporting on relevant formats
to competent authority shall be done.
c) All mandated relevant displays and signage
shall be maintained as per PCPNDT guidelines.
2. Signages RSO/ PNDT Nodal Officer
2.1 Statutory Signages: All safety & statutory signangs & HOD
displays as per AERB & PCPNDT guidelines shall be
placed inside/outside all equipment rooms (as per
guidelines).
The displays shall be in languages & formats as per
guidelines.
For PCPNDT, copy of registration certificates &
display regarding non declaration of sex of fetus in
prescribed format, shall be done in every room
where USG/ ECHO equipment is installed.

2.2 Informative signage – At the minimum following

information signages shall be displayed(using
appropriate languages, font sizes & format) at eye
level. The signage shall be static & permanent (i.e.,
no standees, posters, running scripts):
a) Services provided with room numbers.
b) Timings
c) Directions
d) Safety related education signages
X Ray rooms – as (2.1)& (2.3)
US/Echo – as above (2.1)

2.3 Safety signage – Radiation safety

Radiations safety signages: Safety signage should be
as recommended by AERB including restrictions of
patient/attendant entry, hazard lights and pictorial
signages appropriate for radiology services (
Example picture given) outside of the radiation

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rooms.
At the minimum, following signage shall be used
outside all rooms where X ray, fluro, CT equipments
are installed.

and

MRI safety : Pictorial signages regarding absolute

contra indications to MRI. MRI Pictorial display
regarding absolute contraindications to MRI &
warnings regarding hazards associated with metallic
objects in MRI room.
2.4 Display of telephone numbers to be contacted for
respective safety codes e.g., code blue/code
red/code violet in all rooms where I/V contrast is
given.
3 Equipment HOD/Senior Technician In
charge
3.1 Procurement & installation of equipments shall
be as per government rules.
3.2 Operation of equipment shall be by
appropriate personnel qualified & trained for
the specific jobs
3.3 Daily calibration shall be performed by the
operator technician at the time of switching
on in the morning.
3.4 Daily cleaning of cleanable parts of the
equipment shall be ensured by the operator
at the time of switching off.
3.5 Periodic maintenance (preventive) & periodic
calibration & QA shall be done by the service
engineers from the AMC/CMC provider. The
records shall be maintained by the Technical
In charge.
3.6 Department shall maintain an equipment log
book with information regarding all
equipment under the following categories:
a) Main Imaging Equipment - e.g., X ray, US,
CT, MRI machines, injectors, Boyles
apparatus

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b) Each unit shall be identifiable with a

traceability number as reflected on the
unit & in the log book.

3.7 All equipment shall have dedicated history sheet

where details regarding purchase, operation,
functionality, maintenance & breakdown shall
be maintained.
3.8 Inventory of all accessory and ancillary
equipment.
4 Staff/Personnel HOD
4.1Availability of appropriately qualified and trained
staffs as per the scope of services.
4.2 Availability, job descriptions, rosters, leave
records etc shall be ensured as per
government guidelines/rules.
4.3 Appropriate numbers and mix of the following
staffs shall be available to provide patients
services for routine & emergency imaging.
a) Radiologists – Consultants & Resident
doctors
b) Technical Staff
c) Nursing staff
d) Ancillary staff
e) Data Entry Operator
4.4 Nursing staff may be required in the
department, where contrast
injections/sedation/invasive procedures are
being carried out.
4.5 All Staff shall be trained on respective core
activity & work under supervision during
induction period (1 week).
4.6 Training of all staff shall also be periodically
done for the following at the minimum:
i. BLS
ii. BMW waste rules
iii. Radiation safety
iv. Infection control practices
5 Materials HOD/Technician I/C of store
5.1 Consumables and non consumable materials
required in the department shall be listed in a
log book e.g., -

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Consumables – Films, contrast media, signages,

saline, injectors etc.
Non Consumables – Protective devices (lead
aprons), cassettes, screens, grids etc
5.2 The procurement shall be as per government
rules.
5.3 Storage shall be in safe place with appropriate
environment control.
5.4 Appropriate stock & inventory shall be
maintained to prevent stock outs,
overstocking of slow moving items & expiry of
items without utilization. Good inventory
practices like Vital, Essential, Desirable (VED),
First Expiry First Out (FEFO), ABC* etc shall be
used.
5.5 Record of issuing & consumption shall be
maintained & periodically sent to appropriate
authority.
5.6 All instances of stock outs/non-moving
stocks/expired stock shall be logged &
analysed. It shall be reported to appropriate
authority &Corrective and Preventive Action
(CAPA) shall be suggested.
6 Drugs & Medication
6.1Medication shall include the following: Staff nurse/Technician
a) Contrast media – I/V – nonionic/ionic
b) Contrast media – oral
c) MR contrast media – I/V
d) Medicines for patients preparation e.g.,
buscopan, Lasix, betablockers, GTN etc
e) Medication for resuscitation in crash cart/
Emergency Tray
f) Medicines for sedation/anesthesia
g) Gases – piped gases, oxygen
cylinders/nitrous oxide cylinder

6.2 Procurement shall be as per government rules

6.3 Storage shall be in safe place with appropriate
environment control.
Appropriate stock & inventory shall be
maintained to prevent, stock outs, overstocking
of slow moving items & expiry of items without
utilization. Good inventory practices like Vital,

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Essential, Desirable (VED), First Expiry First Out

(FEFO), ABC* etc shall be used.
6.4 Record of issuing & consumption shall be
maintained & periodically sent to appropriate
authority.
6.5 All instances of stock outs/non-moving
stocks/expired stock shall be logged & analysed.
It shall be reported to appropriate authority &
CAPA shall be suggested.
7 Patient workflow protocol
Arrival of patient in radiology department: Deptt. Staff/ Technician
7.1 A central reception/help desk will
register/schedule the patient for imaging as
per the request form.
7.2 Transport of patient from OPD/ IPD shall be
the responsibility of the sender department.
7.3 One trolley & wheel chair shall be available in
the department to shift a critical patient to
ICU/ward, in case of an adverse event.
7.4 Central reception/help desk shall be
responsible for providing the following
information the to the patients –
a) Date & time of imaging
b) Preparation like NPO, full bladder etc.
c) List of items like towel/water bottle etc to
be brought.
d) Any patient coming for imaging requiring
contrast injection/sedation/intervention
shall be instructed to be accompanied by
a responsible adult/next of kin.
e) Case of queries regarding routine
medication shall be addressed
by/referred to available
radiologist/doctor in the department.
f) Method and time for collection of report
8 Appropriateness/justification: Radiologist
8.1 All imaging request forms will be duly filled by
the referring clinician, with appropriate
indication & clinical details, details of previous
imaging, provisional diagnosis, current clinical
questions (if relevant)
8.2 These details shall be verified by a radiologists
before scheduling the study.

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8.3 Current best practices, availability of equipment

and patient safety shall be kept in mind while
choosing the appropriate imaging for a
particular clinical situation.
8.4 In case the imaging request is found
unjustified/unsafe/unavailable, further
clarification shall be sought from the referring
doctor before accepting it.
8.5The above shall be re-verified on the day of
imaging by the radiologist on duty at
respective imaging stations.
9 Scheduling
9.1 Scheduling shall be done on first come first
scheduled basis taking into account the
capability of the imaging services.
9.2 Priority slots shall be kept for Emergent and
Urgent studies,Indoor patients, Intensive care
patients.
9.3 Pediatric patients, senior citizens, other
vulnerable patients, and patients on certain
medication (e.g., Diabetics) shall be prioritized
on the day of study by the operator in-charge.
10 Patient Information Staff nurse/technician
10.1 Instructions regarding NPO/ Full Bladder etc.
Accompanying person shall be given in
writing, at the time of scheduling
10.2 All the details of the procedure will be
explained to the patient by the staff nurse or
technician.
10.3 Prior to imaging radiologist shall confirm that
informed consent has been taken.
10.4 Information about report collection shall be
given at the time of imaging. Help desk
reception also shall be empowered to provide
the information.
10.5 Follow up imaging advice shall be provided by
the radiologist verbally/documented in the
report.

11 Informed Consent Sister/Technician

11.1 Where there is contrast
injection/sedation/invasive procedure, a

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formal Informed consent will be documented.

11.2 The Consent will document the indications,
benefits, risks and possible alternatives to the
proposed procedure.
11.3 It will be signed and dated by the Radiologist,
Patient/guardian and an impartial witness.
11.4 Pre entry risk assessment checklist can be
included in the consent format.

12 Pre-entry safety check/risk assessment:

12.1 For X-ray/plain CT , last menstrual period (LMP)
shall be ascertained, and documented,
wherever appropriate to ensure that
unnecessary radiation exposure is not given to
pregnant women.
12.2 For contrast injection, a check list containing
history of allergy, HT, DM, renal disease,
cardiac disease, asthma, must be checked &
documented; preferably as a part of consent.
Recent Serum creatinine levels shall be
documented to screen for renal dysfunction.
12.3 For MRI a checklist containing risk of pace
maker, magnetic material i.e., any operative
iatrogenic implants (cochlea implant,
orthopedic implant, aneurysm clip etc) must
be checked & documented.
12.4 For invasive/intervention procedures INR must
be checked & documented in addition to risk
of contrast, as part of consent.
12.5 Separate consent shall be taken for sedation.
13 Patient Identification
13.1 Correct patient must be identified for correct Technician/Radiologist/
procedure at the time of performing the Nurse
procedure, compiling the report and during
dispatch of report. At least two identifiers
shall be used to identify correct patient, one
of which shall be UHID number.
13.2 At the time of imaging , correct patient for
correct imaging of correct side/site shall be
ensured by the technician/radiologist
performing the imaging. Radiologist/technician
13.3 All images will be appropriately labeled for

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patient ID, side marker & date of examination.

13.4 At the time of compiling the report, patient ID
shall be verified by the radiologist on the
envelope, request form, imaging films &
reports.
13.5At the time of report dispatch, the
technician/dispatch desk person shall ensure
correct report for correct patient by using at
least 2 identifiers.
14 Patient preparation:
14.1 Removal of metallic artifacts, change of Nurse/technician
clothing, wherever required.
14.2For ultrasound, change of clothing, filling or
emptying of bladder wherever required.
14.3 For CT, change of clothing, removal of metallic
articles wherever required.
14.4 For MRI, change of clothing, removal of
metallic, magnetizable artifacts.
14.5 Oral contrast water/air, rectal
contrast/water/air, IV line wherever
appropriate
15 Performance of the procedure:

15.1 Procedure for taking plain X ray

a) For most x-ray examinations(except x-ray of
abdomen& spine) no special preparation
is required.
b) As with most other imaging procedures,
jewelry and other metallic articles should
be removed and handed over to the
accompanying person.
c) Patient is appropriately positioned and
asked to hold breath/ be still while film is
exposed.
15.2 Performing Barium studies Technician/Radiologist/
a) NPO Reporting Nurse
b)Preparation as advised at the time of
booking depending on area to be
examined.
c) Change of clothes and removal of metallic
articles/jewelry.
d) Administration of barium suspension as

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appropriate to examination.
e) Patient appropriately positioned & images
taken, keeping ALARA principle in mind.
15.3 Performing Urographic examinations Technician/Radiologist/
a), b) & c) as above. Reporting Nurse
d) informed consent as above of no.11
e) IV line cannulation for injection of
appropriate amount of contrast.
f) Patient appropriately positioned & images
taken, keeping ALARA principle in mind.

15.4 Performing USG/Doppler Radiologist/Nurse

a) Patient arrives as scheduled with full
bladder for pelvic area and NPO for
abdominal examination.
b) Radiologist performs the scan using
appropriate transducer with assistance of
staff nurse.
c) Observations recorded and report
generated by Radiologist.

15.5 Performing CT Scan Technician/Radiologist/

a) Patient arrives as scheduled with Reporting Nurse
requisition form & preadvised
preparation.
b) Can be contrast or non contrast
examination
c) For contrast examination-informed consent
as above
d) All metallic objects removed from area of
interest.
e) Patient positioned for area to be examined
f) IV contrast is injected in appropriate
quantity.
g) Scanning is to be done choosing
appropriate protocol as per indication
h) Post processing of acquired images.
i) Filming in soft tissue, lung, bone window as
appropriate in minimum of films in all
requisite information.
j) Reporting by Radiologist.

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15.6 Performing MRI Scan Technician

a), b)& c) same as CT Scan
d)contraindications to be checked
e) Patient positioned for area to be examined.
f) IV contrast if required
g) Post contrast acquisition.
h) Post processing if required.
i) Filming of required sequences
j) Reporting by Radiologist.

15.7 Performing interventions

a) Ensure availability of attendant /referring
doctor
b) Proper procedure risk assessment &
investigation as appropriate (BT/CT/INR
etc)
c) All aseptic precautions to be taken
d) Universal precaution to be followed all
the time
e) Done under USG/Fluoro/CT guidance
f) Proper labeling and identification of
sample
g) Appropriate dispatch of collected
samples to be ensured by
sister/radiologist to referring
department/concerned lab.
h) Patient to be monitored post procedure
as required.
i) Inform patient regarding report
collection

16 Radiation protection:
16.1 AERB guidelines and ALARA principle will be Technician/Radiologist
followed for all radiation exposures
16.2Patient Protection: Appropriate imaging,
ascertaining pregnancy status of female
patients, use of gonadal covers/lead shields
wherever appropriate, use of low dose
exposures, especially for children.
16.3Staff protection: Appropriate rosters/rotation Technician & RSO
of technical staff from radiation to non-
radiation areas. Provision of radiation
protection barriers/ lead apron/ thyroid
shield, lead goggles/ gonadal shields wherever
appropriate.

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Provision of TLD badges for monitoring of radiation

exposures.
Radiation workers shall mandatorily be wearing the
TLD badges during working hours.

16.4Leakage surveys of installation sites of all

radiation equipment to ensure that staff,
patient &visitors to the department are
protected. Entry to radiation rooms shall be
restricted by suitable signages and red light.
Attendants assisting the patient shall be
preferably males. Female attendants shall be
screened for pregnancy status.
17 Processing films/ images
17.1 After exposure and completion of procedure,
films will be processed by the available
methods.
Wet processing is discouraged. If still in use,
the technician/ dark room assistant will
ensure availability of required solutions at
appropriate concentration & temperature,
every day. Maintenance of automatic
processor.

17.2 Dry view /laser/computer methods of image

processing are preferred. The choice will
depend on the daily throughputs.
17.3 The images will be checked for quality, patient
identity, and urgency of reporting, at the time
of compiling them for reporting in respective
envelopes.
17.4 The technician in charge shall ensure that
these envelopes shall reach the reporting
station in separate piles for ‘urgent’ &
‘routine’.
17.5 Processing of CT/MRI images shall be done by
the radiologist to ensure that all findings and
regions are represented on the films with
appropriate annotations wherever necessary.
18 Report compilation: Radiologist
18.1 Radiologist will ensure compilation of an ‘in

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context’ report taking into consideration the

clinical details provided by the referring
clinicians.
18.2 Patient identity will be checked by the
radiologist while compiling the report.
18.3 Quality of X ray/ other images will be ensured
to be of diagnostic value. Repeat scans will be
ordered if deemed necessary.
18.4 The timeline of reporting will be adhered to, as
per the defined turn around time by the
department.
18.5 Turn around time for the report: The
department/hospitals shall be required to
define the turn around time of the radiology
reports in two categories for each modalities
–
a) Routine report (not more than 48 hours)
b) Urgent (not more than 6 hours)
Emergency report will also be intimated to the
treating physician verbally/telephonically.
18.6 The contents of the report shall include the
following, at the minimum--
a) Patient identification
b) Type of study, region, projection
c) Whether any I/V contrast/oral contrast
given. Please indicate the name, dose,
rate of contrast & whether any adverse
events (AE) occurred.
d) Details of any medical
preparation/sedation, if given.
e) Salient findings (positive & negative)
f) Provisional diagnosis
g) Differential diagnosis
h) Follow up advice, if any.
19 Dispatch of report/ Handover Staff/Technician

19.1 The department will ensure separate dispatch

of report for emergency, OPD and IPD
patients.
19.2 The patient/accompanying person shall be
informed at the time of imaging, how, when &
from where the dispatch of report will be

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done
19.3 For IPD patients, the departmental orderly will
personally collect/dispatch the report
For OPD patient, the dispatch will be done
from a common dispatch center in the
department.
19.4 For ER patients the orderly from Radiology
department shall personally deliver/collect
the report.
19.5 At the time of dispatch, it shall be ensured by
checking patient identifiers that correct report
is handed over to the correct patient.
20 Maintenance of records Technician / office staff
20.1 All the departmental records shall be classified
as under:
a) Office Files
b) Leave records
c) Equipment records
d) Monitoring records
e) Material & consumable records
f) patient workload related data
g) Records pertaining to patients (e.g., request
forms, consent forms, reports and images
(hard/soft copies)
h) Others/miscellaneous

20.2 Records pertaining to patients shall be stored

in retrievable conditions for at least 2 years.
20.3 MLC records shall be in a separate cupboard
under lock & key as per rules (in
department/MRD section).
20.4 All other office / maintenance records shall be
retained as per GNCTD rules.
20.5 Department will ensure that blank forms &
format for reporting are available in the
department.

21 Codes HoD

Display of contact number (rescue number) for all

relevant codes.
Code Blue: All staff in Radiology department

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shall be trained on CPR at least 6 monthly.

Doctors (radiologists shall be BLS/ACLS
trained). Liaison with the hospitals code blue
team shall be done for smooth rescue.
Code blue teams shall be made. Mock drills
shall be carried out at least 6 monthly to
ensure compliance.
Code Red & code violet: Desirable
22 Inventory Control Technician/Store keeper
22.1 Departmental inventory of material shall be
maintained by the store In charge or
technician incharge.
The following shall be defined for each items
a) Buffer stock
b) Reorder level
22.2 Issue register shall be maintained & kept up to
date
All instance of stock outs/ non moving
stock/expired unused stock shall be logged &
analysed in departmental committee for
appropriate CAPA.

23 Equipment maintenance– repair & PMS/Technician/Radiologist

downtime management
23.1 Downtime of equipment clause shall be
incorporated in every equipment
maintenance contract
23.2 Contingency plan for downtime of each
equipment shall be documented. It will ensure
uninterrupted patient service.
23.3 Periodic preventive maintenance calendar for
all equipment shall be available along with
contact details of each vendor.
23.4 Response time for complaints shall be
monitored for each equipment.
23.5 Timely renewal of maintenance contract &
statuary compliance shall be ensured.

24 Day to day working of the department HOD Radiology

HoD shall ensure the following (at minimum) for

smooth day to day functioning of the department

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a) Rosters
b) Leave Records
c) Grievance handling
d) Disciplinary procedure
e) Facility Management
f) Housekeeping
g) The HoD will take daily/weekly, scheduled
and unscheduled rounds to ensure good
facility management & housekeeping
* ABC analysis divides an inventory into three categories- "A items" with very tight control and accurate records,
"B items" with less tightly controlled and good records, and "C items" with the simplest controls possible and
minimal records.

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