X-Ray Images -
Written Evaluation Policy
Name of responsible (ratifying) committee / Radiology IRMER Group through Medical Radiation Committee to Trust Clinical Governance
Date ratified / 12 February 2015
Document Manager (job title) / Louis Merton – Clinical Director Diagnostic Imaging
Martin Firth – Consultant Radiologist and IRMER lead
Janine Hatch – Imaging Services Manager
Catrin Ferioli – Trust Radiation Protection Adviser
Date issued / 13 February 2015
Review date / 12 February 2016
Electronic location / Clinical Policies
Related Procedural Documents / See section 8 of this policy
Key Words (to aid with searching) / IRMER Written Evaluation Evaluation; Reporting procedures; Radiologists; Medical staff; Reports.
Version Tracking
Version / Date Ratified / Brief Summary of Changes / Author4 / 12/02/2015 / Change of document manager names, change of document format / IRMER GROUP
CONTENTS
QUICK REFERENCE GUIDE
1.INTRODUCTION
2.PURPOSE
3.SCOPE
4.DEFINITIONS
5.DUTIES AND RESPONSIBILITIES
6.PROCESS
7.TRAINING REQUIREMENTS
8.REFERENCES AND ASSOCIATED DOCUMENTATION
9.EQUALITY IMPACT STATEMENT
10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
APPENDICES:
Appendix 1:
PHT Radiology department, other departments and procedures supported with X-ray equipment…..9
Appendix 2:
PHT Radiology reporting schedule and specialty arrangements……………………………………… 10
Appendix 3:
Specialties with arrangements for medical staff to undertake the role of IRMER Practitioner………11
Appendix 4:
Exceptions……………………………………………………………………………………………………12
Appendix 5:
Access to Radiologists……………………………………………………………………………………..13
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural documents.
For quick reference the guide below is a summary of actions required. This does not negate the need for the document author and others involved in the process to be aware of and follow the detail of this policy. The quick reference can take the form of a list or a flow chart, if the latter would more easily explain the key issues within the body of the document
- This document details means by which statutory responsibilities for making a written record of the evaluation of radiological examinations/procedures are met.
- The primary duty to ensure that the written record of the evaluation of a radiological examination/procedure is made rests with the referring specialty – referrer (Appendix 2)
- Written evaluations may be undertaken by others on behalf of the Referrer where documented agreements are in place, e.g. with Radiology for radiologists reports.
- Referrers are able to seek specialist opinions, assistance or support from Radiologists in the Radiology Access Unit (RAU) (Appendix 5).
- Referrals for radiological procedures constitute one part of the patient’s management. It is the responsibility of the referrer to ensure that the request is documented to ensure the use of resultant information to inform decisions concerning further management of the patient.
- Elements of the process may be delegated to a suitably trained and qualified professional but the ultimate responsibility for the quality of medical care rests with the Consultant (Practitioner) responsible for the patients care.
- Application and effectiveness of this policy is monitored through Audit and overseen through Audit reports and exceptions by the Quality and Governance Committee
1.INTRODUCTION
All X-ray images taken as part of diagnosis, treatment, ongoing medical management and research must have a traceable record of the image being evaluated by a recognised medical practitioner or allied health professional delegated with this responsibility. This is a legal duty under the Ionising Radiation (Medical Exposures) Regulations 2000 (IRMER)1. Any exposure to X-rays is unjustifiable if it is known in advance that the images will not be evaluated.
2.PURPOSE
This policywill ensure the implementation of the statutory requirement for written evidence of clinical evaluation of medical X-rays in all clinical areas, contributing to appropriately documented medical records.
3.SCOPE
The policy applies to the evaluation of all X-ray images of patients referred to and examined in Portsmouth Hospitals Radiology departments, by PHT Radiology staff or by others using X-ray equipment on Portsmouth Hospitals NHS Trust premises, extending also to other departments and services where X-ray imaging is employed in diagnosis and treatment, e.g. Cardiology, Pain Clinic, Radiotherapy, Nuclear Medicine. These are listed in detail in Appendix 1.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognizes that it may not be possible to adhere to all aspects of this document. In such circumstances, staff should take advice from their manager and all possible action must be taken to maintain ongoing patient and staff safety’
4.DEFINITIONS
Evaluation:
A documented evaluation is a record that evidences the examination of an X-ray image, or analysis of X-ray data, leading to a decision concerning the clinical status of the subject related to the initial purpose for which the X-ray exposure was undertaken.
From IRMER: "evaluation" means interpretation of the outcome and implications of, and of the information resulting from, a medical exposure;
Referrers:
All PortsmouthHospitals and MoD MDHU medical and dental staff are eligible to refer patients for x-ray examinations. Individual allied health professionals can be authorized as referrers for specified examinations by arrangement with the Radiology department. Medical staff using image intensifier equipment are considered to be referrers, unless covered by specified arrangements detailed in Appendix 3
Referrals should conform to the Portsmouth Hospitals Radiology Referral Guidelines (available via the intranet) or be by prior discussion with a Radiologist.
Internal departmental procedures will apply where X-rays are part of other investigations or treatments in Nuclear Medicine and Radiotherapy.
From IRMER: "referrer" means a “registered healthcare professional” who is entitled in accordance with the employer's procedures to refer individuals for medical exposure to a practitioner; "registered health care professional" means a person who is a member of a profession regulated by a body mentioned in section 25(3) of the National Health Service Reform and Health Care Professions Act 2002."
Record:
The record may be a Radiologists report, clinicians record in the patients notes which indicates use of the radiological information in diagnosis or treatment, marking up of films or images, treatment decisions or outcomes (e.g. “wires correctly located”) related to the procedure, printed data from analysis of X-ray data (e.g. DEXA scan results). A list of procedures that constitute exceptions is given in Appendix 4
5.DUTIES AND RESPONSIBILITIES
Referring specialties are responsible for recording the evaluation of all radiographs, whether returned as films or on PACS. This may be by a delegated allied health professional within the specialty. The responsibility extends to evaluation of features relevant to the clinical question / reason for referral, against which the examination has been carried out.. Exceptions to this are where a report is provided by a radiologist, or as specified in Appendix 2 - PHT Radiology reporting schedule and specialty arrangements.
Supporting opinion:
Referrers may at any time seek assistance or support from more experienced colleagues within their own specialty, on request from a radiologist in the RAU (Appendix 5 – Access to Radiologists), or by making a specific request to a Radiologist. This may include seeking an opinion concerning a suspicion of abnormal pathology that is beyond the reason for the original referral.
Ongoing clinical care of the patient:
It is the referrers / referring medical practitioner’s responsibility to make it clear in the notes that a referral for a radiological investigation has been requested. Where images are subsequently provided by radiology, these must be evaluated and a record made in the notes / on PACS by the medical practitioner dealing with the patient at the time, and in consultation with colleagues within the medical team where additional expertise is required.
Liability:
Medical staff (not trained as radiologists) shall only be responsible for the validity of the evaluation as it relates to the reason for referral and within the scope of their own expertise. Suspicious pathology should however be identified wherever possible and a supporting opinion sought in such cases.
Elements of the process may be delegated to a suitably trained and qualified professional but the ultimate responsibility for the quality of medical care rests with the Consultant responsible for the patients care.
The referring clinician should liaise with colleagues to discuss interpretation of routine referrals and seek opinions from experienced and senior colleagues in cases where their experience is limited. Use should be made of the RAU (Appendix 5 – Access to Radiologists) to discuss individual cases, areas of suspicious pathology etc. Requests for radiologist’s reports should be the exception where there is no reporting agreement in place.
The Patient Safety Steering Group, with support from the Medical Radiation Committee, will oversee the application of this policy in conjunction with agreements and referral practices as monitored by Radiology.
6.PROCESS
ACTION / RATIONALE / EVIDENCE / Potential Risks/HarmsAll investigations or treatments using X-rays must have documented evaluation in the patient’s notes. / Adoption of best practice in clinical management of patients.
Compliance with statutory obligations under IRMER. / Reference1 / Unnecessary use of radiological investigations and exposure to X-rays.
Inadequate clinical care
Risk of enforcement action /prosecution for non-compliance with statutory responsibilities
ASPECT OF CARE / OUTCOMES
/ EXPECTED STANDARD / TARGET / SOURCE OF DATA COLLECTIONWritten evaluation of X-ray procedure in the patient’s notes / 100% of investigations / treatments / Periodic audit
External inspection by the CQC IRMER team
Radiologists report where required within existing agreements / 100% of investigations / treatments / Periodic audit
External inspection by the CQC IRMER team
7.TRAINING REQUIREMENTS
Medical staff will have received basic training in the interpretation of X-ray images during the undergraduate and foundation years. Further training relevant to their specialty is acquired during the SPR appointment.
Competency will be achieved through completion of the CCST (Certificate of Completion of Specialist Training). This is under the jurisdiction of the Specialty Training Schemes.
Non-medical staff undertaking evaluation of images are trained through individual training plans under the supervision of a Reporting Radiographer and a nominated Radiologist.
Allied Health Professionals undertaking X-ray procedures within departments of Nuclear Medicine and Radiotherapy will adhere to local procedures approved by their lead Practitioner.
Specialty Consultants undertaking the role as IRMER Practitioner must have qualifying training as detailed in IRMER Schedule 2.
8.REFERENCES AND ASSOCIATED DOCUMENTATION
1Ionising Radiations (Medical Exposures) Regulations 2000. Statutory Instrument 2000 no 1059
also
The Ionising Radiation (Medical Exposure) (Amendment) Regulations 2006 Statutory Instrument 2000 No. 2523
2 DOH Guidance for IRMER
[ARCHIVED CONTENT] The Ionising Radiation (Medical Exposure) Regulations 2000 (together with notes on good practice) : Department of Health - Publications
3 RCR Guidelines – Making the Best Use of a Department of Clinical Radiology
Guidelines for Doctors. Sixth Edition
4 Portsmouth Plain Film Referral Guidelines
X-Ray Request Form
9.EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably practicable, the way we provide services to the public and the way we treat our staff reflects their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
Our valuesare the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They are beliefs that manifest in the behaviour our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision to be the best hospital, providing the best care by the best people and ensure that our patients are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our Trust:
Respect and dignity
Quality of care
Working together
Efficiency
This policy should be read and implemented with the Trust Values in mind at all times.
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)Page 1 of 13
10.MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement to be monitored / Lead / Tool / Frequency of Report of Compliance / Reporting arrangements / Lead(s) for acting on Recommendations100% of investigations / treatments will have written evaluation in patient’s notes / CSC Management Team / Periodic Audit / Annually / Policy audit report to:
- Annually IRMER Group
Imaging Services Manager
100% of investigations / treatments will have Radiologists report where required within existing agreements / CSC Management Team / Periodic Audit / Annually / Policy audit report to:
- Annually IRMER Group
Imaging Services Manager
This document will be monitored to ensure it is effective and to assurance compliance.
The effectiveness in practice of this Written Evaluation of X-rays Policy will be routinely monitored (audited) to ensure the document objectives are being achieved. The standards against which such audits are undertaken are defined in section 6– Process.
In addition:
- Additional entitlements to non-medical referrers will be developed by the Radiology department and confirmed in IRMER Standard Operating Procedures through the Radiology IRMER Group
- Exceptions will be identified and reviewed by the Radiology IRMER Group and where significant reported to Patient Safety Steering Group in the IRMER compliance report.
- Adverse incident forms will be raised for significant non-compliances. All incidents involving ionising radiation exposure are reviewed by the Trust Radiation Protection Adviser and where required, notified to the Care Quality Commission according to requirements of IRMER legislation.
- The Medical Radiation Committee will be responsible for receiving the results and monitoring action plans as required.
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)Page 1 of 13
APPENDIX 1:
PHT Radiology departments, other departments and procedures supported with X-ray equipment
This appendix lists the Portsmouth Hospitals facilities to which this policy applies for radiological procedures.
Radiology departments at
- QueenAlexandraHospital (QAH)
- Emergency Department at QAH
- Dental Units at QAH
- Paediatric Department
- RDCU
- X-ray and scanning
- Gosport War Memorial
- PetersfieldHospital
- FarehamCommunityHospital
- Radiographic procedures on wards and in theatres using mobile X-ray equipment at QAH
- Fluoroscopy assisted procedures in theatres and in departments using mobile C-arm image intensifier systems at QAH
- Fluoroscopy assisted procedures using permanently installed equipment, or mobile equipment owned by specialties, e.g. Cardiology, Orthopaedics, Radiotherapy
- Radiographic procedures undertaken with a department’s own X-ray equipment, e.g. Orthodontics/Maxillofacial, Nuclear Medicine, Radiotherapy.
- Breast screening and breast imaging procedures undertaken with mammographic equipment in mobile trailers as part of the Portsmouth Breast Screening programme
- Radiotherapy treatment planning simulators, CT scanning, and portal imaging devices
- CT scanning equipment installed at QAH
- Any additional facility leased, owned or rented by Portsmouth Hospitals is support of its own clinical activity.
In addition to the above, this policy shall also apply to individual procedures undertaken by any other organization where a specific arrangement has been made for patients under the care of Portsmouth Hospitals NHS Trust.
APPENDIX 2
PHT Radiology reporting schedule and specialty arrangements
The following investigations and procedures are all the responsibility of Portsmouth Hospitals Radiology department Radiologists;
- CT
- Interventional procedures undertaken in the X-ray departments at QAH
- Fluoroscopy procedures undertaken in the X-ray department at QAH (may also be undertaken by an Advanced Practitioner Radiographer)
- All General Practitioner imaging procedures referred directly to Radiology
- Emergency Department radiography (may also be undertaken by a reporting radiographer)
- Paediatric procedures undertaken in the radiology department (appendix 1) (may also be undertaken by a reporting radiographer)
- All imaging requested by Non-medical referrers.
General adult in and out patient films will not be routinely reported by a Radiologist. Reference should be made to the PHT Plain Film Reporting and Evaluation Policy which discusses this in detail.
This list may be added to by agreement with the relevant speciality
Unreported inpatient films can be discussed in the Radiology Access Unit (RAU), at regular MDT or clinico-radiological meetings. To avoid unnecessary interruptions to Radiologists in the RAU with attendant risk of errors and reduced efficiency, routine requests for opinions on inpatient or outpatient images can be made by emailing
This group mailbox is reviewed regularly throughout the day and images added to the PACS HOTSEAT worklist for Radiologist review. Clinicians can also request a Radiological report on images by completing a ‘Request for Report on Plain X-ray’ form, available at the reception desk in Radiology Day Case Unit at QAH.
APPENDIX 3
Specialties with arrangements for medical staff to undertake the role of IRMER Practitioner
The following specialties are responsible for the documentation of the evaluation of the radiological procedures, other than those where a referral is made directly to PHT Radiology services. Specialty Consultants undertake the role of IRMER Practitioner for their field by virtue of eligible training (also section 8) and/or local agreement.
- Radiotherapy / Oncology
- Cardiology
- Respiratory Medicine
- Pain Clinic
- Gastroenterology
- Orthopaedics (use of Fluoroscan only)
- Urology
- General and Vascular Surgery
APPENDIX 4
Exceptions:
The following lists those radiological procedures where a documented evaluation is not required;
- Individual fluoroscopy and electronic radiographic images taken as part of a complex procedure where the information is used to assist a surgical intervention. However the outcome of the procedure must be recorded, and which may include reference to any final image taken for verification or for the patient records.
- CT fluoroscopy procedures undertaken as part of an interventional procedure. However the outcome of the procedure must be recorded, and which may include reference to any final image taken for verification or for the patient records.
- Procedures aborted owing to patient or technical factors where no useful information could be obtained. A record must however be made of the fact that the procedure could not be successfully completed.
- Repeat radiographs as a result of patient or technical factors where image quality is inadequate for the purpose of the procedure.
- Films or images taken as part of planning a subsequent procedure, e.g. CT ‘scanogram’, test-shots for subtraction Angiography
- Films or images marked up for the purpose of planning subsequent treatment or intervention, including also images for radiotherapy treatment planning. A marking on the image and demonstrable use of the data is sufficient to demonstrate compliance.
- Examinations undertaken where results are analyzed by computer and retained in storage systems with the original procedure data, e.g. Dual-energy X-ray Absorptiometry scans (DEXA scans) for osteoporosis.
APPENDIX 5