RD 003 Objectives, Goals and Functions

HMG/QAS/RD/003
Issue Date: 07/01/2020

Effective Date: 14/01/2020
RADIOLOGY DEPARTMENT (RD) Review Date : 13/01/2022
Title: Objectives, Goals and Functions
1.0 Definitions and Abbreviations:
1.1 PPM - Policy & Procedure Manual

1.2 DOR - Department of Radiology
1.3 CT - Computed Tomography
1.4 MRI - Magnetic Resonance Imaging
1.5 BMD - Bone Mineral Densitometry
1.6 DEXA - Dual Enhancement X-ray Absorptiometry
1.7 PACS - Picture Archiving and Communication System
2.0 Purpose:
To ensure that the following medical services: general and conventional diagnostic
radiology; special examinations and procedures such as ultrasound examinations;
BMD/DEXA; other diagnostic technique like whole body CT, MRI for inpatients,
outpatients and emergency patients has properly provided.
3.0 Policy:
This policy defines the objectives, goal and functions of the Department of Radiology.
4.0 Procedure and Responsibilities:
Responsible
Sr. No. Procedure Sequence
Person
Goal: The main goal for the department is to provide prompt
and adequate diagnostic service with a minimum cost and less P.R.O/
risk for the patient. The purpose of our service is to define our Clinical Engineers
4.1
relationship with our patients and interested groups (wards,
clinics) for the patients’ situation and for what kind of service
we can give to our patients.
Objectives: In choosing a diagnostic imaging technique, one
should select the one with the greatest utility (with the highest
sensitivity and specificity) and the least risk to the patient. One Radiology
should minimize the cost, the risk and radiation exposure to the Technician/
4.2 patient. COST/BENEFIT: The cost and risk of any particular Radiology Doctor
diagnostic technique must be weighed against the benefits to be
derived from such examinations. Cost benefit considerations in
diagnostic imaging are of great importance in our present daily
medical practice.
Functions: The main functions of the Department of Radiology
4.3
are the following: Radiology
Provide general conventional radiology which is composed of Technician
4.3.1 skeletal radiography, plain radiography without the use of any
contrast media.
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Provides special X-ray procedures like contrast media Radiology
4.3.2 examinations of the gastro-intestinal, genito-urinary tract, Technician/
reproductive, neuro-radiology and vascular examinations. Radiology Doctor
Perform whole body computed tomography (C.T.) including CT Technician
4.3.3
dynamic C.T. scanning.
Perform ultrasound imaging of the different soft tissues and Ultrasound
4.3.4
parenchymatous solid organs. Technician
X-ray, CT and/or ultrasound guided punctures or biopsies. Interventional
4.3.5
Doctor
Limited interventional procedures or techniques with Radiology
fluoroscopic and/or ultrasound guidance. Technician/
Ultrasound
4.3.6
Technician/
Interventional
Doctor
Mammography. Female Radiology
4.3.7
Technician
Provides MRI procedures which include routine MRI and MRA MRI Technician
4.3.8
studies.
4.3.9 BMD
Special procedures that are not available at present in the
Radiology
hospital like isotope scanning are referred to the nearest
4.3.10 Technician
hospital after taking an appointment, and if he/she is in-patient
he/she will be transferred by the ambulance car of the hospital.
BASIC DIAGNOSTIC PRINCIPLES - Radiography consists
4.4
of three steps:
Examination of patient with fluoroscopy or exposure of an Radiology
4.4.1
digital x-ray Technician
4.4.2 Processing of digital x-ray image for documentation.
Reading or interpretation of the images from various imaging
4.4.3 procedures by diagnostic radiologist and transcription of Radiology Doctor
reports.
The ultrasound examination process is almost the same as
above in the since that the patient is examined with a transducer Ultrasound
(sound generating equipment) and the signals are converted to a Technician/
4.4.4
T.V. image (monitor) then the image is frozen and sent to the PACS Admin
PACS. Ultrasound is a non-invasive technique and does not
have any potentially harmful radiation.
Computed Tomography - is a complex diagnostic examination
with the use of radiation but is also non-invasive in general, CT Scan
4.4.5
unless supplementary contrast media injections are required for Technician/
further evaluation. Radiology Nurse
4.4.6 The patient is positioned in an examining table. The organ to be CT Scan
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Person
examined is placed in the gantry (opening) where radiation and Technician
detection takes place. Computers are used to store the
information and images are then reconstructed or re-formatted
and documented in films as required
MRI is an advanced imaging tool using radio waves and strong
magnetic fields to acquire image of whole body including blood MRI Technician
4.4.6.1
vessels and at time supplementary contrast media is required
for further evaluation
4.5 Operational Function (1-12)
4.5.1 Schedule of normal working hours:
General: It is of the utmost importance in a modern Head of
Department of Radiology that all the staff personnel work Department/
continuously at the same time examining patients and Senior Technician/
performing the different operational systems in order that the Chief of
high standard of quality diagnostic examinations or procedures Radiology/
4.5.1.1 Radiology
is maintained. It is therefore very vital for all the modern
diagnostic procedures to be performed at a definite period and Technicians
course of time in order that the necessary quality of
examination, procedure and documentation will be exact and
reliable for interpretation and reporting.
Staffing schedules are done by the Supervisor of Unit/Senior Chief Technologist
4.5.1.1.1 and signed by the Chief Technologist before submission to the / Supervisor/
administration. Senior
The due date for the submission of the Employee Time Record
4.5.1.1.2 to the Accounting Department is on the 1st day of every Time Keeper
month.
It is the responsibility of the Chief Technician and head of the Head of
4.5.1.1.3 department to check the accuracy of the time and supporting Department/
documentation. Chief Technician
On-call schedules must be done as needed by the Chief Chief Technician
4.5.2.2
Technologist.
For the Department of Radiology the normal working hours
should be: Saturday thru Thursday from 8:00 A.M. to 10:00 Chief Technician/
P.M. Extended working hours will be covered during other Senior Technician
4.5.2.3 timings apart from the above mentioned normal working hours
to accommodate the inflow and convenience of the patients.
Special and invasive procedures should be done during the
normal working hours.
Hours of duty or on-calls may only be altered with the Head of
4.5.2.4 permission of the Chief Radiologist and Chief Department/
Technician/Radiographer. Chief Technician
Overtime hours or excess hours should be in agreement with Chief Technician
4.5.2.5
employment contractual policy.
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Employees are required to record their attendance on the All Staff
4.5.2.6
Employee Time Record machine placed at the designated area.
All absence from work through sickness or other reasons must
have prior written approval by the Employee Health Physician Treating Physician
4.5.2.7
or his/her designee and the department head. See "Sick Leave
Formalities- Personnel Policy"
Request for annual leave, additional due days off must be
4.5.2.8 submitted in writing in accordance with the Company Hospital Technicians
Employment Policy.
Develops and maintain a standard procedure manual for
4.5.2 diagnostic examination to assure high standards of
performance.
Develops, maintains and improves diagnostic patient
4.5.3
preparation procedures.
Develops and maintains a good priority scheduling procedure Quality
to assure an efficient and prompt operational service in order to Coordinator
4.5.4
accomplish optimum utilization of the available facilities and
personnel.
Provide effective training programs and competent supervision
4.5.5
to assure high standards of performance.
Coordinate and improve cooperation with other medical
4.5.6
personnel/ward/clinics to insure optimum patient care.
Monitor the radiation exposure dosage of Radiology personnel
4.5.7 and filing of records of radiation monitoring data to be kept in
the Department of Radiology. R.S.O.
Give instructions in safety precautions, radiation protection
4.5.8
rules and participate in radiation safety program.
Give instructions in safety precautions, radiation protection
4.5.9
rules and participate in radiation safety program
Participate in the continuing medical education committee Quality
functions. Coordinator/
4.5.10
Chief Technician/
Technicians
Provide consultation on quality assurance, monitoring Quality
functions. Coordinator/
4.5.11
R.S.O/
Chief Technician
4.6 Scope of Operation
Taking the necessary documentation of images and assuring Quality
that quality or results are satisfactory for interpretation Coordinator/
4.6.1
purposes and that the results will be put in legible form and Chief Technician
made available for the patient's permanent record.
4.6.2 Scheduling special examinations requiring preparation and Receptionist/
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Responsible
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giving proper instructions for some of the patients or ward Nurses/
nurse. Technicians
Emergency examination will be given their proper priority and Technicians
4.6.3
care will be taken not to extend patient's injury.
Facilities: Radiology service area is located in Lower Ground Technicians/
4.7 Floor Chief Technician/
Nurse
4.8 Communications
Telephones: Emergency telephone numbers of Radiology
4.8.1 personnel are available through the hospital switchboard for use
in an emergency situation.
The Radiologist on call, technicians on call for Ultrasound, Doctor/
4.8.2 C.T. Scan, and MRI are called through the telephone operator Nurses
for emergency purposes only
Routine X-Ray Examinations Performed in the Radiology
4.9
Department:
SKULL
4.9.1.1 Facial bones
4.9.1.2 Mandible
4.9.1.3 Mastoid
4.9.1.4 Maxilla
4.9.1
4.9.1.5 Nasal bones
4.9.1.6 Orbits Radiology
4.9.1.7 Pituitary fossa (sella tursica) Technician/
4.9.1.8 Sinuses Doctors/
4.9.1.9 T-M Joint Treating
CHEST Physician/
4.9.2 4.9.2.1 Ribs Radiologist
4.9.2.2 Sternum
ABDOMEN
4.9.3
4.9.3.1 K.U.B
SHOULDER
4.9.4
4.9.4.1 or Acromio - clavicular Joint Scapula
CLAVICLE
4.9.5
4.9.5.1 or Sternoclavicular Joint
UPPER EXTREMITIES
4.9.6.1 Humerus (arm)
4.9.6.2 Elbow
4.9.6 4.9.6.3 Radius and Ulna (Forearm)
4.9.6.4 Wrist (Scaphoid)
4.9.6.5 Hand
4.9.6.6 Fingers
4.9.7 PELVIS
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4.9.7.1 or Hip Joint
4.9.7.2 Sacro-iliac Joint
LOWER EXTREMITIES
4.9.8.1 Femur ( thigh)
4.9.8.2 Knee
4.9.8 4.9.8.3 Tibia and Fibula (lower Leg)
4.9.8.4 Ankle
4.9.8.5 Foot (Calcaneus)
4.9.8.6 Toes
VERTEBRAE Radiology
4.9.9.1 Cervical Spine Technician/
4.9.9.2 or soft Tissue of Neck Doctors/
4.9.9.3 Thoracic Spine ( Dorsal) PT/
4.9.9 Radiologist
4.9.9.4 Lumbar Spine
4.9.9.5 Sacrum
4.9.9.6 Coccyx
4.9.9.7 Whole Spines (For Scoliosis)
Special X-Ray Examinations to be Performed in the
Department (Appointment Necessary):
4.10.1 Barium Enema with or without Air Contrast Study
4.10.2 Barium Swallow ( for esophagus)
4.10.3 Cystogram
4.10.4 Intravenous Urogram ( Pyelogram)
4.10.5 Retrograde Pyelogram
4.10.6 Sialogram
4.10.7 Sinogram
4.10 4.10.8 Small Bowel Series (Barium Meal)
4.10.9 Ultrasound Examinations
4.10.10 Urethrogram (s)
4.10.11 Venogram
4.10.12 Hysterosalpingogram ( by Gynecologist/Female
Radiologist)
4.10.13 Mammography
4.10.14 C.T. Scan Studies
4.10.15 MRI studies
4.10.16 B.M.D.
4.11 Manual for routine radiographic examination:
Humerus (must include shoulder joint)
Doctor/
4.11.1.1 A.P.
4.11.1 Radiologist/
4.11.1.2 Lateral
Radiology
4.11.1.3 Transthoracic Projection (by request only)
Technician
Shoulder Joint
4.11.2
4.11.2.1 A.P.(Neutral Position)
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4.11.2.2 Modified Axial View-(30-45 degrees Body
Rotation)
4.11.2.3 Transthoracic Position (for fracture or
Dislocation case, Erect only)
4.11.2.4 Y-view (15-25 Body Rotation BA)
Acromioclavicular Joint
4.11.3 4.11.3.1 AP only ,Both sides with Weight Bearings
4.11.3.2 A.P. only, Both sides w/o Weight Bearings
Clavicle
4.11.4
4.11.4.1 AP @ 25 Degrees Cephalad
Scapula
4.11.5 4.11.5.1 AP
4.11.5.2 Lateral
4.11.6 Lower Extremities:
Foot
4.11.6.1 AP (Dorso-plantar Projection)
Oblique ( Medial Rotation)
Except Foreign Body case (put a mark at point of entry)
4.11.6.2.1 AP
4.11.6.2
4.11.6.2.2 Lateral
4.11.6.2.3 Oblique
Toes
4.11.6.3 4.11.6.3.1 AP of Foot
4.11.6.3.2 Oblique ( Medical Rotation)
Calcaneous (Oscalsis)
4.11.6.4 4.11.6.4.1 AP (45 Degrees Angled)
4.11.6.4.2 Lateral
Ankle Joint
4.11.6.5.1 AP
4.11.6.5
4.11.6.5.2 Lateral
4.11.6.5.3 Ankle Joint (Mortus View)
Leg Upper (with knee joint)Lower (with ankle joint)
4.11.6.6 4.11.6.6.1 AP
4.11.6.6.2 Lateral
Knee Joint
4.11.6.7.1 AP
4.11.6.7.2 Lateral
4.11.6.7
4.11.6.7.3 Skyline view(by request only)
4.11.6.7.4 Tunnel view (Intercondyloid Fossa) (by
request only)
Except: Foreign Body case (put a mark at point of entry)
4.11.6.8 4.11.6.8.1 AP
4.11.6.8.2 Lateral
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Patella
4.11.6.9.1 Lateral
4.11.6.9
4.11.6.9.2 Skyline view
4.11.6.9.3 Tunnel view (by request only)
Femur-Upper (with hip joint)Lower (with knee joint)
4.11.6.10 4.11.6.10.1 AP
4.11.6.10.2 Lateral
Pelvis
4.11.6.11
4.11.6.11.1 AP only
Hip Joint
4.11.6.12.1 AP
4.11.6.12 Radiology
4.11.6.12.2 Crosstable of Frog leg (Not for trauma or
post-operative case) Lateral Technician/
Chest Doctors/
4.11.6.13.1 P.A. 180 cm distance (it must be mark on Treating
the image if its portable or sitting etc.) Physician/
4.11.6.13 4.11.6.13.2 Lateral ( For chest related disease Only) Radiologist
4.11.6.13.3 Apical Lordotic Projection (by request
only)
4.11.6.13.4 Decubitus (Projection ( by request only)
Ribs Series
4.11.6.14 4.11.6.14.1 PA of Chest 180 cm
4.11.6.14.2 Right and left oblique
Sternum
4.11.6.15 4.11.6.15.1 RAO ( 10 ,Degrees Angled Cephalad)
4.11.6.15.2 Lateral
Sternoclavicular joint
4.11.6.16 4.11.6.16.1 PA
4.11.6.16.2 Oblique ( 30 Degrees)
4.11.7 VERTEBRAL COLUM
Cervical Spine
4.11.7.1.1 AP (10 Degrees Angled Cephalad)
4.11.7.1 4.11.7.1.2 Lateral (Neutral 72 inches distance)
4.11.7.1.3 Both Obliques (45 Degrees) by request only).
4.11.7.1.4 Flexion & Extension Laterals (by request only)
Except: Trauma Case (Cervical Spine)
4.11.7.2.1 Lateral (C7 must be obtained)-Cross
4.11.7.2
Table
4.11.7.2.2 AP Open Mouth (Odontoid)
Neck-Soft Tissue
4.11.7.3
4.11.7.3.1 Lateral
Neck- Foreign Body
4.11.7.4
4.11.7.4.1 One Lateral Only (with marker)
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Thoracic Spine
4.11.7.5 4.11.7.5.1 AP
4.11.7.5.2 Lateral
Lumbar Spine
4.11.7.6.1 AP
4.11.7.6.2 Lateral
4.11.7.6.3 Coned Down Lateral L5-S1 ( additional
4.11.7.6
view in case of space of L1 is not visible.
4.11.7.6.4 Both Obliques (45 Degrees ) by request
only
4.11.7.6.5 Flexion extension as per request only.
Except : Trauma Case
4.11.7.7.1 AP
4.11.7.7 Radiology
4.11.7.7.2 Lateral
4.11.7.7.3 Coned Down L5-S1 Technician/
Sacrum Doctors/
4.11.7.8 4.11.7.8.1 AP ( Angled 35 Degrees Cephalad) Treating
4.11.7.8.2 Lateral Physician/
Coccyx Radiologist
4.11.7.9 4.11.7.9.1 AP (Angled 10 Degrees Caudad)
4.11.7.9.2 Lateral
Sacro-iliac Joint
4.11.7.10 4.11.7.10.1 AP ( Angled 35 Degrees Cephalad)
4.11.7.10.2 Oblique (25 Degrees)
Scoliosis
4.11.7.11.1 AP
4.11.7.11
4.11.7.11.2 Lateral (Standing) **Center at the
concave of the vertebrae)
Skeletal Bone Survey (to be slightly over penetrated)
4.11.7.12.1 A.P. & Lateral or Dorsal Spine
4.11.7.12.2 AP & Lateral if Lumbar Spine
4.11.7.12 4.11.7.12.3 AP of Pelvis
4.11.7.12.4 AP of Both Femurs
4.11.7.12.5 AP of Both Humerus
4.11.7.12.6 Skull AP & Lateral
4.11.8 Other Examinations :
K.U.B
4.11.8.1
4.11.8.1.1 AP Including Partly Diaphragm)
Acute Abdomen Radiology
4.11.8.2.1 PA of Chest ( Erect 72" distance) Technician/
4.11.8.2 4.11.8.2.2 Supine Abdomen Doctors/
4.11.8.2.3 Erect Abdomen (Including Diaphragms) Treating
4.11.8.2.4 DECUBITUS (for those patients who are Physician/
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unable to make erect position) Radiologist
NOTE:
For trauma of children less than 14 years, if x-ray of
shoulder, elbow, knee or ankle is requested take the
unaffected side and the affected side two views, each view of
both side in one film.
4.11.8.3
In case of foreign body, marker at the level of site of entry Radiology
should be placed on the film ( not patient surface) Technician/
All fluoroscopic examination such as Barium Examination Doctors/
performed by the Radiologist and fluoroscopy should not be Treating
done by the Technician independently. Physician/
The Following examinations are done under presence and Radiologist
4.11.8.4 instruction of Radiologist. This is only the guidelines for
Radiology Technologist and Nurses
4.12 I.V.P (Intra Venous Pyelogram): Radiology Nurse
Plain film or K.U.B Radiology
4.12.1
Technician
After contrast injection Radiology
4.12.2
Technician
At 5 minutes for kidneys
Compression and wait for 5 minutes
At 10 minutes film for kidneys Radiology
4.12.2.1
Release compression and take K.U.B. at 15 minutes Technician
At 30 minutes take film for urinary bladder 15-30 angled
downwards
Post-voiding bladder film for all male patients
a. Esophagus  Fluoroscopy and Spot films.

(Barium  (Follow the Radiologist
Swallow) Instruction)
Optional Radiology
overhead Technician
films
 Fzluoroscopy and Spot films.
4.12.2.2 b.
 Overhead films (follow the
Flouroscopy
Radiologist instruction)
 After following the U.G.I. Series
every 30minutes or one(1) hour of
c. Small
interval, PA of Abdomen, until
Bowel Series
Barium Sulfate reach the caecum
and Ileum Area. (Follow the Radiology
Radiologist Instruction) Technician
d. Barium  Fluoroscopy and Spot films.
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Enema & Air  P.A. of Abdomen (Prone Position)
Contrast  Both Debucitus (by Radiologist
Instruction)
Magnetic Resonance Imaging: MRI is the most advanced
technique in Diagnostic Imaging using very high static
magnetic field radio-frequency (RF) pulses. No invasive in MRI Technician/
general but potentially hazardous for the patients with cardiac Radiologist/
pacemakers, and ferrous implants like intra-cranial aneurysm Doctor
clips etc.., patient is positioned in an examining table with the
part to be examined is placed closure to the specified
4.12.2.3 receive/transmit Radio frequency coils and placed in the iso
centre of the super conducting magnet. Polarization of the
body’s nuclei takes place and then matching radio frequency to
the resonating nuclei in the anatomy of interest is sent in and
turned off. Now the body emits a signal which is received by
the receiver coil. Sophisticated computer is used to reconstruct
and store MRI images from these signals. MRI images are
documented in PACS system.
DEXA BMD: (Dual Enhanced X-Ray Absorptiometry Bone
Mineral Densitometry). A quantitative imaging technique that X-ray Technician/
uses X-Ray radiation source to measure bone mineral density. Doctor/
4.12.2.4 BMD is a measurement of bone mineral found in the region of Radiologist
interest. BMD is derived using BMC divided by area, where
BMC is measured in gram and area is measured in centimeter
squared.
CT scan: Computerized Tomography Scan is one of the
advanced imaging tools. It uses ionizing radiation (X-Ray) to
scan the parts of the human body. Various examinations can be
done from head to toe using different techniques in different
CT Technician/
planes wherever applicable. Non contrast CT scan
4.12.2.5 Doctor/
examinations of brain, spines, extremities etc., do not have
Radiologist
specific preparation. Contrast examinations and CT guided
Biopsies and aspirations have specified patient preparation.
Oral contrasts are given to specify the G.I.T (Gastro intestinal
tract).
Specific consent from the patient should be for I.V. contrast as Treatment
4.12.2.6
well as CT guided aspiration or biopsies. Physician
Ultrasound: It is non-invasive imaging tool which uses
ultrasound waves. Usage of specific ultrasonic probes for Radiologist/
4.12.2.7 different regions brings out live images which are frozen and Ultrasound
recorded on paper. It is very useful in diagnosing the Technician
abdominal parts, obstetrics study, musculoskeletal etc.
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5.0 References :
5.2 Joint Commission International Accreditation 6th Edition, 2017.

5.3 Saudi Central for Accreditation of Healthcare Institutions 5th Edition, 2015.
5.4 American College of Radiology, Version 10.1, 2015.
6.0 Distribution List
6.1 General Director

6.2 Executive Director
6.3 Medical Director
6.4 Director of Nursing
6.5 Quality Improvement Office
6.6 Radiology Department
6.7 OR Department
6.8 Cathlab Department
6.9 Dental Department
6.10 Out Patient Department
7.0 Policy Review History
Edition No. Revision Original Clause Revised Clause Remarks

Date No. No.
Edition No. 1 January 2009 ----- ----- New Policy
Edition No. 2 January 2011 ----- ----- Updated policy
Edition No. 7 January 2020 ---- ---- Updated policy
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RD 003 Objectives, Goals and Functions

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RD 003 Objectives, Goals and Functions

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HMG/QAS/RD/003

Issue Date: 07/01/2020

1.0 Definitions and Abbreviations:

1.1 PPM - Policy & Procedure Manual

4.0 Procedure and Responsibilities:

a. Esophagus  Fluoroscopy and Spot films.

5.2 Joint Commission International Accreditation 6th Edition, 2017.

6.0 Distribution List

6.1 General Director

7.0 Policy Review History

Edition No. Revision Original Clause Revised Clause Remarks

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