Radiology Services

Policies and Procedures

July 2012

Radiology Policies and Procedures

Table of Contents

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Inspection of Radiology Equipment

Maintenance of Radiology Equipment and Radiographs

Operation of Radiology Equipment

Outgoing Film Identification for Transport

Patient Examination

Patient Identification

Permanent Identification of Radiographs

Persons permitted in the Radiology Examination Room

Physician Order

Radiology Services at University Health Services

Transportation of X-Ray Films for Interpretation

X-Ray Film Checkout

June 2012Revised Approved SUBJECT POLICY: PURPOSE

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Jume 2012 Revised Approved by: ______________________________________ Office of Student Affairs ______________________________________ Director, University Health Services ______________________________________ Medical Director

OPERATION OF RADIOLOGY EQUIPMENT: POLICY:

All equipment controlled by the Radiology Department is to be operated by licensed Radiologic Teachnologists 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 Signature Date

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June 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 in front office 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 provider referred to, date of scheduled appointment and mode of transport must be provided to the Radiologic Technologist (RT) directly or through voice mail.

3. If the RT is not available, the front office staff will sign out the requested films and reports by following the “X-Ray Film Check Out” policy.

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. An X-Ray Film Check Out form and an Authorization to Release Medical Records/Information form will be attached to the film envelope. These must be filled out

before the x-ray is released to the patient. These release forms will be returned to the x-ray office or placed in the Incoming X-Ray box in front office.

2. If the RT is on duty, the film will be prepared, release forms filled out and film handed directly to the patient.

3. If the RT 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 RT is not available at time of the request for immediate access, the check-out film policy with release forms 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.

Annual Review

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June 2012

Revised

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

SUBJECT: PATIENT EXAMINATION POLICY: Patients will receive a radiology examination performed by and under the service of a licensed Radiologic Technologist. GUIDELINES: 1: Patient will be identified by with the Radiology Orders 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 X-Ray 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 X-Ray 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

Signature Date

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June 2012

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

SUBJECT: PATIENT IDENTIFICATION POLICY: Patient identification will be verified before a radiology examination. The Radiologic Technologist is responsible for correctly identifying the patient to be examined. A Radiology order will accompany the patient to the Radiology Department, and the Radiologic Technologist is to check the order to verify the ordered examination. A Notre Dame ID may be requested for identification purposes. GUIDELINES: 1: Prior to the examination, the Radiologic Technologist verifies the patient’s name. 2: Prior to examination, inform the patient of the procedure and answer any questions relating to the radiology examination being performed. 3: Direct patient to return to physician after determining the quality of the radiology study. PATIENT IDENTIFICATION

Annual Review

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June 2012

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

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

- Procedure - Diagnosis

2: Patient or accompanying staff member will provide the Radiology Technologist with the patient‟s encounter form. The Radiologic Technologist will complete the „Radiology Order” form.

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

Annual Review

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June 2012

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

SUBJECT RADIOLOGY SERVICES AT UNIVERSITY HEALTH SERVICES POLICY University Health Services will provide limited on-site diagnostic imaging for its population

of patients who have a physician order for a specific radiological 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: Radiology 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 9:30 AM-4:30 PM, Monday through Friday. When radiology service is not available, or the x-ray schedule cannot accommodate due to high volumes, patients will be sent to the appropriate off-campus facility for the diagnostic imaging examination. 3. UHS staff will check out x-ray films for patient or outside provider request when Radiologic Technologist is not available.

PROCEDURE 1: The Radiologic Technologist will receive written orders from a physician or from the registered nurse approved by a University Health physician. 2: The patient is directed to the Radiology Department by the registered nurse where the Radiologic Technologist completes the physician order form based on order written on encounter form. 3: The patient prepares self 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 radiology study, the patient is directed back to the physician at UHS, along with x-ray film, and physician will perform initial review of the x-ray and discuss his/her interpretation with the patient. 5: The x-ray film will be delivered to a Radiologist and the end of the day by courier. The Radiologist will interpret the x-ray; a written report is faxed to UHS within one business day. Abnormal results are phoned to a UHS physician 6: 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 is also filed in the patient’s film jacket. X-RAY FILM RELEASE PROCEDURES A patient’s original x-ray may be loaned out for referrals if they are to be returned. Copies must be made if the referring physician requires them for his/her files. 1: The patient is identified by name, date of x-ray 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 x-ray exam (finger, hand, foot, etc.) to be signed out on the front of the original film jacket. 2: An Authorization to Release Medical Records/Information (Exhibit I)and an X-ray Check Out form (Exhibit II) must be completed, signed and placed in the original jacket. The jacket should then be re-filed in the radiology examination room. 3: The x-ray films and the radiologist’s interpretation 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 x-ray film, the patient is informed that the films are original records and must be returned to University Health Services by the patient or the physician to whom the films were sent. An X-ray Check Out form is to be filled out by the patient requesting the film study and placed in the patient’s original film jacket. 5. Information sheet titled “Please Return Our X-Rays Within 60 Days” is placed in every outgoing x-ray film envelope. (Exhibit III)

Annual Review

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June 2012 Revised

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

POLICY: TRANSPORTATION OF X-RAY FILMS FOR INTERPRETATION PROCEDURE: 1: All X-Ray films will be transported to a radiologist by courier at the end of each day. 2: All X-Ray films must be signed out on the Daily Log and Destination Form. (Exhibit I). The log remains in the Radiology Department. 3: X-ray films will be returned to University Health Services within 2 business days. A copy of the radiologist’s written interpretation is placed in the patient’s film jacket. Annual Review

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June 2012Revised Approved

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AUTHORIZATION TO RELEASE MEDICAL RECORDS/INFORMATION

Patient: ____________________________ NDID:_____________________ Date of Birth:_______________

Current Address: _____________________________________________________________________________

Recipient: __________________________________________________________________________________

Address: ___________________________________________________________________________________

University Health Services (“UHS”) is hereby authorized to discuss with and/or release to Recipient information

(including records, reports, tests, histories, diagnosis, prognosis, etc.) obtained or made in connection with

evaluation of Patient’s medical condition.

Reason for disclosure: Medical History______ X-ray Films______ Immunization Records______

Walk Out Statements______ Other______

It is understood by the undersigned that he/she may revoke this consent as to his/her medical records/information at

any time except to the extent that action has been taken in reliance thereon. It is also understood that this consent

shall remain valid for sixty (60) days from the date of signature unless the consent is revoked prior to the expiration

of sixty (60) days or a date, event, or condition is designated below upon which the consent will expire:

_____________________________________________________________________________________________

_____________________________________________________________________________________________

Signature of Patient (or guardian): ______________________________ Date: ____________________

Date of Graduation (if applicable): _______________________

UHS IS NOT authorized to release mental health records/information, alcohol and/or drug treatment

records/information or communicable disease records/information (“Sensitive Medical Records”) except

when reportable by law to public health agencies or unless specifically authorized to do so below.

Sensitive Medical Records Release

By signing below, I am authorizing the above UHS to discuss and/or release to Recipient information about

my Sensitive Medical Records, as designated below.

Mental Health _____________

Alcohol and/Drug Treatment______________

Communicable Diseases (e.g. – Aids, HIV, hepatitis) _______________

Other (Specify) __________________

It is understood by the undersigned that he/she may revoke this consent as to his/her mental health records at any

time except to the extent that action has been taken in reliance thereon. It is also understood that this consent shall

remain valid for one hundred and eighty (180) days from the date of signature unless the consent is revoked prior to

the expiration of one hundred and eighty (180) days or a date, event, or condition is designated below upon which

the consent will expire:

_____________________________________________________________________________________________

___________________________________________________________________________

Signature of Patient (or guardian):_________________________________ Date: _______________

Physician’s Approval: ___________________________________________ Date: _______________

(Required for Release of Sensitive Information from UHS medical record)