HMG/QAS/RD/001

Issue Date: 07/01/2020

Effective Date: 14/01/2020
RADIOLOGY DEPARTMENT (RD) Review Date : 13/01/2022
Title: Overview and General Information

1.0 Definitions and Abbreviations:

1.1 DOR - Department of Radiology

1.2 OB&G - Obstetrics & Gynecology
1.3 ICU - Intensive Care Unit
1.4 E.R - Emergency Room
1.5 CSSD - Central Sterile Supply Department
1.6 PACS - Picture Archiving and Communication System
1.7 STAT reports – quick report

2.0 Purpose:

To define and overview the general information about the Department of Radiology
as providing the highest standards of practice and high quality care to the patients
referred to Department of Radiology.

3.0 Policy:

This procedure manual defines the actions and responsibilities of the Radiology Staff
to the diagnostic service provided to the patient referred thereto.

4.0 Procedure And Responsibilities:

Responsible
Sr. No. Procedure Sequence
Person
The Department of Radiology (DOR) is covered on 24-hour
All Radiology
4.1 per day basis. The “on-call” hours are rotated. Schedule is
Staff
published and posted in the DOR and E.R.
4.2 The DOR is under the supervision of the following:
The Chief Radiologist is a member of the medical staff and is
4.2.1 responsible for the overall supervision of the entire H.O.D
department.
The Chief Radiographic Technician is responsible for
organizing and supervising technical functions under the Chief of
guidance of the Chief Radiologist and in accordance with Radiology/
4.2.2
hospital policy scheduling hours and assigning duties, Radiology
orienting, instructing and supervising personnel, maintaining Technician
supplies and equipment, maintaining department records.
4.3 Personnel Requirements:
Refers to job descriptions for positions in this department Radiology
4.3.1
which is in a separate file. Technician
Refers to personnel policies which cover all hospital Quality
4.3.2
employees. Coordinator
4.4 Examinations and Procedures Performed:
4.4.1 Refers to enclosed list of radiographic examinations and Radiology

Page 1 of 7
 HMG/QAS/RD/001
Issue Date: 07/01/2020
Effective Date: 14/01/2020
RADIOLOGY DEPARTMENT (RD) Review Date : 13/01/2022
Title: Overview and General Information

Responsible
Sr. No. Procedure Sequence
Person
procedures available in this institution. Technician
Scheduling Examination and other Procedures for Receptionist
4.5
Patients:
Routine Examinations - All examinations are performed as Radiology
4.5.1 soon as possible after electronic requisition is received. Technician /
Fasting patients are scheduled as early as possible. Receptionist
Examination in a Series - Refers to enclosed instructions for
scheduling examinations in series. Due to period of time Receptionist/
required for patient preparation and sequence in which these Radiology Nurse/
4.5.2 examinations should be performed, X-rays in a series must be Radiology
scheduled accordingly. Physicians and nursing personnel Technician /
must be aware of these requirements when requesting such Radiology Doctor
X-rays.
Apart from the procedures that need preparation, all other Radiology
procedures are done immediately. For the procedures that Technician /
4.5.3
need preparation, appointments may be made by physicians Receptionist
or patients with radiology department for such examinations
Outpatients service – Out-patient's examinations are Receptionist/
performed on 24 hours basis. Appointments may be Radiology Nurse/
4.5.4 made by physicians or patients with radiology personnel for Radiology
examinations or other radiology services needing special Technician /
procedure (preparation). Radiology Doctor
4.6 Priority:
Normally all examinations requested on a given date will be
performed on that date and if possible in the order Radiology
4.6.1
requisitions are received, except for fasting patients who are Technician /
scheduled as early as possible. Receptionist
Orders marked for specific time will be complied with as
4.6.2
closely as possible.
Urgent requisitions are given consideration (priority) over all Radiology
4.6.3
others. Technician
Employee X-rays are usually scheduled when work load is Senior X-ray/
4.6.4
light. Technician
4.7 Instructions to Nursing Units:
All instructions for patient preparation for routine and special
examination or procedures normally performed in this
hospital. As soon as the nurse receives word of a scheduled Radiology Nurse/
examination or procedure from Radiology, the inpatient nurse Radiology
4.71
in-charge is responsible for preparing the patient in Technician
accordance with the instructions and established procedure.
This includes orders for medication, diet, fasting time,
elimination, etc.
4.7.2 Instructions for examinations or procedures that need special

Page 2 of 7
 HMG/QAS/RD/001
Issue Date: 07/01/2020
Effective Date: 14/01/2020
RADIOLOGY DEPARTMENT (RD) Review Date : 13/01/2022
Title: Overview and General Information

Responsible
Sr. No. Procedure Sequence
Person
preparations are given to nursing personnel at time the Nurses
electronic requisition is received.
In case of any failure to receive request electronically, Radiology
4.7.3
manual request for is filled up. Technician
4.8 Transportation of Patient to and from Department:
Patients are transported to and from Radiology by personnel
from the Nursing Department. Such personnel are responsible
for patient's safety in transit and for complying with Department
4.8.1 established safety regulations. If patient cannot be moved, a Nurses/
mobile unit is taken to location of patient by technician after Radiology
the approval from the referring physicians for such Technician
examinations which shall adhere all safety precautions.
4.9 Examinations and Procedures in the Department:
Inpatients are gowned in nursing unit, and all metal materials
removed from patient's body, e.g. jewelry, hairpins, etc.
Outpatients are gowned and prepared in radiology
department. Patients are oriented to procedure and their
participation. Clean fresh linens are used for each patient. Radiology
Soiled linens are disposed off according to proper procedure. Technician /
4.9.1 Equipment to be used is checked for cleanliness, and proper Nurses
functioning prior to use.
Asepsis is applied in all handling and treatment to patient as
dictated by infection control. Technician is responsible for
patient protection through careful observation of safety rules
and regulations in the use of equipment, positioning of
patient, etc.
When contrast media is required, it is prepared according to
instructions on container and administered by the Radiologist Radiologist
to the patient. Crash cart is available in case of adverse
4.9.2
reactions. Container is not disposed off until the patient is
considered out of danger. If complication arises contrast
media reaction procedure is followed.
Only qualified Radiographic Technicians are permitted to
take x-ray examinations. Equipment and procedure manuals
describe equipment and supplies to be used and procedures to
4.9.3
be followed in each type of examination or procedure.
(Includes operation of equipment, positioning and protection Radiology
of patient, image transmission to PACS) Technician
When it is determined that a clear image has been obtained,
the patient is returned to the specific unit or dismissed, unless
4.9.4
indicated otherwise by the physician as in the case of broken
bones, foreign objects, etc.
4.9.5 Image is properly labeled and identified on system and send Radiology

Page 3 of 7
 HMG/QAS/RD/001
Issue Date: 07/01/2020
Effective Date: 14/01/2020
RADIOLOGY DEPARTMENT (RD) Review Date : 13/01/2022
Title: Overview and General Information

Responsible
Sr. No. Procedure Sequence
Person
to the PACS. Technician
Processed images are sent to the specific Radiologist via
PACS for interpretation and a report of his or her findings.
4.9.6 Reports are charted as soon as they are dictated, typed and Radiologist
signed (approved). URGENT/PANIC reports are called to
physician and documented.
4.10 Examinations and Procedures: (In other departments)
When a patient cannot be moved, a portable x-ray/ultrasound
unit is taken to the patient's room and technician/Radiologist
takes the x-rays performs the required procedure in Radiology
4.10.1 compliance with established policy of the department in Technician /
which the patient is located, e.g. surgery, isolation, O.B., Radiologist
I.C.U., E.R., etc., under supervision. Refer to individual
department policies
4.11 Radiology Reports:
After interpretation of the study, the radiologist will report
4.11.1
his findings which is done by voice recognition.
Transcribed reports must be approved by the Radiologist Radiologist
before they can be filed with the patient's records. STAT
4.11.2
reports must be communicated to the attending physician as
soon as interpretation is finished.
4.12 Outgoing Film:
CD’s is released to patients on demand after being reported Receptionist
4.12.1
by Radiologist.
4.13 Records – Clerical Duties:
Daily clerical duties consist of the following: answering
4.13.1 telephone, taking and delivering messages, typing, filing, Radiology
running errands, requisition request for supplies. Secretary
4.14 Department Log:
All examinations and procedures performed are listed daily in Radiology
4.14.1 the register or log, according to examination or procedure for Technician
statistical and future reference purposes.
4.15 Images and Report File:
Images and reports are can be retrieved from the PACS as PACS Admin
4.15.1
and when required.
4.16 Supplies and Equipments:
Supplies and equipments are established on appropriate form Nurses
4.16.1
from Material Management Department.
All equipments purchases require administrative approval. Head of
4.16.2
Department
Linens are requisitioned from Laundry Unit and send for Laundry
4.16.3
cleaning to the Laundry Unit.
4.16.4 Supplies and equipment not stored in radiology department

Page 4 of 7
 HMG/QAS/RD/001
Issue Date: 07/01/2020
Effective Date: 14/01/2020
RADIOLOGY DEPARTMENT (RD) Review Date : 13/01/2022
Title: Overview and General Information

Responsible
Sr. No. Procedure Sequence
Person
are stored in Material Management Department. Storage of
supplies such as flammable or combustible liquids, gases or
materials, acids are complied with environmental control and
safety regulations. Stationary equipment are checked and Clinical Engineer
approved by qualified surveillance and maintenance
personnel in so far an electrical safety protection are
concerned (includes installation, outlets and the equipment
itself). Safety information (Manufacturer's) must be on the
machines in full view of the operator.
Problems arising from equipment are referred to Clinical
4.16.5
Engineering Department by Maintenance request.
Sterilization of specific equipment is performed by CSSD. CSSD/
4.16.6
Nurse Technician
4.17 Departmental Cleaning:
Equipment is cleaned and decontaminated by department Nurse/
4.17.1 personnel on daily basis or whenever necessary. Radiology
Technician
Work areas are cleaned by housekeeping personnel as Housekeeping
4.17.5
scheduled.
4.18 Infection Control and Safety:
All personnel are trained in infection control and safety
pertinent to their respective departments (areas). Aseptic
technique is applied in handling and treatment of patients. Radiology Staff
Safety measures are applied in checking, care and use of
4.18.1 equipment as outlined in environmental control (esp.
electrical equipment, fire protection), miscellaneous and
patient safety policies. Refers to infection control policies
(manual) as they apply to all patient care and service
departments.
4.19 In-service Education:
Chief Radiologist is responsible for output in the service
4.19.1 education program, and must be available for consultation to Chief Radiologist
medical and nursing staff.
All employees are required to attend in-service education
meetings, classes, demonstrations (hospital-wide and Radiology Staff
4.19.2 departmental). Attendance is recorded at classes pertaining to
infection control, fire protection, and environmental control,
safety measures etc.

5.0 References:

5.1 Joint Commission International Accreditation Standards for Hospitals, 6th Edition,
2017.

Page 5 of 7
 HMG/QAS/RD/001
Issue Date: 07/01/2020
Effective Date: 14/01/2020
RADIOLOGY DEPARTMENT (RD) Review Date : 13/01/2022
Title: Overview and General Information

5.2 Central Board for Accreditation of Healthcare Institutions, 3rd Edition, 2015.
5.3 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 Date. Original Revised Remarks

Clause No. Clause No.
Edition No. 1 January 2009 ----- ----- New Policy
Edition No.2 January 2011 ----- ----- Updated policy
Edition No.3 January 2013 ----- ----- Updated policy
Edition No.4 January 2014 1.0 1.0 Definition added
Edition No.5 January 2016 4.11.2 4.11.2 Amended Clause and
approval block

Edition No.6 January 2018 ----- Changed in policy

Edition No. 7 January 2020 ---- ---- Updated policy

Page 6 of 7

RADIOLOGY DEPARTMENT (RD)
Title: Overview and General Information
HMG/QAS/RD/001
Issue Date: 07/01/2020
Effective Date: 14/01/2020
Review Date : 13/01/2022
Page 7 of 7