Radiology Services Policies and Procedures July 2012

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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 20122 Revised Approved by:

__________________________________________ Office of S Student Affairss __________________________________________ Director, U University Heaalth Services __________________________________________ Medical Director

SUBJECT T: POLICY:

PURPOSE E:

INSPE ECTION OF RADIOLOGY R EQUIPMENTT All radiology equipm ment is inspeccted annually by a state liceensed Physiciist as requiredd by law w. The radiology departmennt adheres to all codes andd regulations. 1. All safety warnings are postedd in highly visiible areas. 2. Raddiation monitoor badge is woorn by radioloogy departmennt personnel dduring working hours. 3. Prootective lead aprons a are useed in all exam ms, whenever possible.

GUIDELIN NES:

Annual Review R Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

Signature

Date Revieewed: Revieewed: Revieewed: Revieewed: Revieewed: Revieewed:

Datee

June 20122 Revised Approved by:

__________________________________________ Office of S Student Affairss __________________________________________ Director, U University Heaalth Services __________________________________________ Medical Director

SUBJECT T:

MAINTE ENANCE OF RADIOLOGY R Y EQUIPMENTT AND X-RAY Y FILMS

POLICY: All radioloogy equipment is maintaineed and inspectted in accordaance with Indiana State and Federal guideliness. PROCEDURE: 1: The film m processor iss maintained on o a monthly cycle by a coontracted licennsed companyy, Berrien X-R Ray. 2: All expoosed film is keept in the requuired leaded bin. b 3: Exposeed films are maintained in a patient’s film m jacket for seeven years, annd are then discarded throuugh the recycle process of x-rays. x 4: Safety lights in the dark room are maintained at the designatted power to aavoid overexpposure of x-raays during proocessing. 5: Film cassettes are maintained m andd cleaned on a weekly bas is to avoid arttifacts on anyy x-ray films. (Exhibit1) Annual Review R Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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Signature Revieewed: Revieewed: Revieewed: Revieewed: Revieewed: Revieewed:

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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 Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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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

2. 3. 4.

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

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Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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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 Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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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 Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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June 20122 Revised Approved by:

__________________________________________ Office of S Student Affairss __________________________________________ Director, U University Heaalth Services

__________________________________________ Medical Director __________________________________________________________________ ____________________________ SUBJECT T:

PERMAN NENT IDENT TIFICATION OF O X-RAY FILLMS

POLICY: The Radioologic Technoologist is to prooduce a properly identifiedd x-ray film PROCEDURE: 1: Side Maarkers: All A x-rays are to have a rightt or left markeer on the film prior to proceessing. Writing W the sidee marker on the t film after exposure e will not constitutee an acceptedd standard. a ordeer and permannently stampeed with the following inform mation: 2: Each fillm will be idenntified by the attached -

Patient P name Date D of Birth Date D of exam Procedure P locaation

R Annual Review Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

Date

Signature Revieewed: Revieewed: Revieewed: Revieewed: Revieewed: Revieewed:

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June 2012 1 Revised Approved by:

__________________________________________ Office of S Student Affairss __________________________________________ Director, U University Heaalth Services __________________________________________ Medical Director

SUBJECT T: PERSONS S PERMITTED D IN THE RA ADIOLOGY EX XAMINATION N ROOM POLICY: Only undeer the discretioon of the Radiologic Technnologist will a person other than the patieent be allowedd in the examination room. GUIDELIN NES: 1: The Raadiologic Techhnologist shalll direct that anny person othher than the paatient involvedd in the x-ray proceduree be excluded from the sam me room durinng the exposuure, except: -

In the judgmeent of the Raddiologic Technnologist or thee physician, a person relateed to the patieent shoould be preseent to assist inn the emotionaal support andd/or the safe hhandling of thhe patient. Forr such excceptions, the related person shall not bee a pregnant w woman. The R Radiologic Technologist assks succh a related person p if they are/could be pregnant. If thhere is any poossibility the pperson is preggnant, theen she will be excluded for the room during the expossure.

2: The Raadiologic Techhnologist shalll require relateed persons too wear a proteective lead appron, lead glovves, and/or thyyroid collars if the procedurre requires such protection during the exxposure. Annual Review R Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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Signature Revieewed: Revieewed: Revieewed: Revieewed: Revieewed: Revieewed:

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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 Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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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 Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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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 Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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June 20122 Revised Approved by:

______________________________________ D Director, Univeersity Health S Services ______________________________________ A Assistant Direcctor, Clinical S Services ______________________________________ R Radiologic Tecchnologist

SUBJECT T:

X-RAY Y FILM CHEC CK OUT

POLICY Any x-ray film that is removed from a patient’s perrmanent x-rayy file must be signed out with proper documenttation. PROCEDURE 1. Remove R requeested x-ray film m from the permanent file eenvelope and place the film m in a travel ennvelope. (Film m copies to bee made upon request.) 2. Make M a copy of the radiology report and place p the copyy into travel eenvelope. Thee original repoort reemains in the permanent x--ray file. 3. Complete C the X-Ray X Film Chheck Out form (Exhibit I) witth patient nam me, date, type of xray, destinnation off film and signnature of indivvidual checkinng out the film . X-Ray Film Check Out foorm is located in the x--ray office. 4. Have the patiennt complete thhe Authorizatioon to Releasee Medical Reccords/Informattion form (Exhhibit II) annd file this in the t individual’s permanent x-ray file envvelope. NES GUIDELIN NEVER give the permaanent x-ray filee envelope to the patient o r use it for traansport for purposes outsidde Universityy Health Services.

X-RAY FILM CHECK OUT Annual Review Signature Reviewed: Reviewed: Reviewed: Reviewed: Reviewed: Reviewed:

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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______ Walk Out Statements______ Other______

Immunization Records______

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

Date: _______________