Download Radiology Procedure Manual

Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
Service Name :
Radiology
Date Created :
15-01-2008
Chief Medical Superintendent
Approved By :
Name
:
Signature :
Medical Superintendent
Reviewed By :
Name :
Signature :
Director
Issued By :
Name :
Signature :
Head of the Department-Radiology
Responsibility of Updating :
Name :
Signature :
0
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
Page of Contents
Sl.Order Particulars
A
Purpose
B
Scope
C
Abbreviations
D
Organization Structure of the Department
E
Departmental Procedures
F
Policies of the Department
G
Registration Certificates
H
Acts
I
Reporting Critical Results
J
Quality Control
K
Patient Education and Safety
L
Reporting of Imaging Test Results
M
Turn Around Time for Reports
N
Criteria for fixing of Appointments
O
Maintenance of Equipment
P
Training of Departmental Staff
Q
Departmental Inventory Management
R
Outsourcing of Imaging Test Not Available in the Hospital
S
Reporting Format for Daily/Monthly Statistics
T
Quality Plan
1
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
A. Introduction:
Radiology is the medical specialty directing medical imaging technologies to diagnose and
sometimes treat diseases. Originally it was the aspect of medical science dealing with the medical
use of electromagnetic energy emitted by X-ray machines or other such radiation devices for the
purpose of obtaining visual information as part of medical imaging. Radiology that involves use of
x-ray is called roentgenology. Today, following extensive training, radiologists direct an array of
imaging technologies (such as ultrasound, computed tomography (CT) and magnetic resonance
imaging) to diagnose or treat disease.
B. Purpose and Scope :
1. The Department of Radiology of the hospital provides comprehensive services in the following
imaging technologies ( a brief description of the same are also stated below) :
i.
ii.
iii.
iv.
General Radiography: X-rays are a form of radiation, like light or radio waves that can be
focused into a beam. Once it is carefully aimed at the part of the body being examined,
an x-ray machine produces a small burst of radiation that passes through the body,
recording an image on photographic film or a special image recording plate
Mobile Radiography: Mobile unit used to X-ray bed ridden patients and sometimes used
to X-ray during operative procedures in Operating Room.
Ultrasound : Ultrasound, or sonography, uses high frequency sound waves to see
inside the body. As the sound waves pass through the body, echoes are produced, and
bounce back to the transducer. These echoes can help doctors determine the location of
a structure or abnormality, as well as information about its make up. Ultrasound is a
painless way to examine internal organs.
Magnetic Resonance Imaging (MRI) : M R scans use magnetic resonance that images
the body from different angles and then use computer processing to show a cross
section of the various tissues and organs pictured .MRI scans have proven to be very
help in diagnosis of soft tissues especially brain , spinal cord , joints, abdomen ,chest
and other muscles.
2.Scope : Provision of comprehensive services in following areas
i.
ii.
iii.
iv.
General X-Ray
Special X-Ray such as HSG
Ultra Sonography
Magnetic Resonance Infraction
2
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
C. Abbreviation:
1. IP
= Inpatient
2. OP
= Outpatient
3. OTC = Over the Counter
4. US
= Ultrasound
5. USS = Ultrasound Scanning
6. RDT = Radio Diagnostic Technology
7. MRI = Magnetic Resonance Imaging
8. OED =Order Entry Done
9. OR
= Operating Room
10. TLD = Thermo Luminescent Dosimeter
D. Organization Structure of the Department :
Head – Department of Radiology
Senior Consultant - Radiologist
Radiology Technician or Radiographers/Staff Nurse
Dark Room Assistants
3
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
E.Departmental Procedures
i. Out Patient with Consultation:
Patient comes with the
requisition form for
investigation
No
Yes
Does the
invstgn need
preparation?
Yes
Is the Pt. with
necessary
preparation?
No
Can the pt.
be allocated
for invstgn?
No
Pt. is told abt the requirement
of appt. & given for the earliest
available time
Yes
After investigation Order entry
done, Code will be entered in
charge sheet
Pt. will come at that date and
time of appt with preparation
Pt. is directed to the
consultant with report or wet
film
Critical reports are informed
by the radiologist to the
consultant verbally
immediately
4
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
ii. In patients
Doctor will prescribe the
investigation to the patient
Nurse will inform about the invstgn and the pt.
will prescribe the
details to Doctor
the dept.
investigation to the patient
The radiographer will check
the kind of test and the need
for pt. preparation
Nurse will
be informed
the time of
invstgn
No
Yes
Is pt. pprtn
needed?
Inform the nurse about the
preparation
The appt. is given
according to the
preparation
No
If Pt. is
prepared?
Yes
The nurse is told to send the pt. to
the dept with patients case sheet.
Invstgn is done and order entry
is entered in charge sheet
Patient is transferred back to the
wing with Nurse.
5
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
iii. Dispatching Wet films :
Dispatching Wet
films
Out-patients
Treating Doctor requests
for the films (for early
consultation with doctor)
Accident & Emergency
Room
No
Yes
Is the films
processed?
Dispatch the films after
obtaining sign of the
receiver
Wait till the films are
ready
Inform the pt. / Nurse to
return back the film for
reporting
Films are dispatched after taking sign from the
Nurse/Patient/Attendant and requested to return
for reporting
No
Is the pt. is
in-patient?
Yes
For OPD, patient/attendant return
backs the wet films to the radiology
reception for reporting
Films will not be handed over to wings
without report in case of emergency
and check x-ray Radiographer will
show and bring it back immediately
Radiologists reports the
films
Films with reports are dispatched
from the Radiology Dept OPD
IP-to wings
Signature of the receiver is obtained
6
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
iv.In-patients / Emergency patients (For all Radiology Procedures) After Duty Hours
Doctor will prescribe the invstgn
to the pt. from wings and from
Accident & Emergency Room
MO/Nurse will inform about the invstgn &
sent the request to Radiology
Is the pt.
preparation
needed?
Yes
No
Check with the nurse whether the pt. is
prepared or not
pt. is prepared
Inform Radiologist / In case after working hours Radiologist
is informed immediately knowing the requirement.
It takes 30 Minutes for the radiologist to reach the hospital
Call the pt. for the necessary investigation
After completion
Order entry done & enter in Pt. Case sheet.
(Before radiologists arrive keep patient and Machine ready
and check patient preparation)
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Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
v.
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
Radiology procedures
Patient comes to the dept with
requisition form
No
Yes
Is the Pt.
Inpatient?
Check whether the preparation
followed by the Pt. is adequate
As the requirements of the pt.,
preparation are taken care from before
by nurse.
Yes
Is
preparation
adequate?
No
Is the time
sufficient for
preparation?
Check the Pt. Identification with
the prescription, and other
details (previous reports if
required)
Send the Pt. for investigation
Yes
Guide the Pt. and wait till the Pt. is
prepared. Then take the Pt. for
invstgn only once when the
preparation completes
No
Guide the Pt. and inform the patent
about the next earliest possible
date/time
8
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
vi. Hystero Salpingogram (HSG)
Doctor prescribes the test
Pt. is informed that she has to make
prior appt. on a specified day of the
menstrual cycle as well as the briefing
about the test
Pt. will make an appt. and comes
on that date for the test
Pt. will be directed to the dept. and
take informed consent and Pre
medication is started half an hour
before the procedure and the test
is performed by the Gynecologist



Once the procedure is over , check patient
condition
Order entry is made ,entered in charge sheet
Patient is informed to meet the consultant &
informed when they will get their report
9
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
Vii .G.I Tract Study
Doctor prescribes the test
Pt. is explained the preparation for
the test, which has to be followed for
two to three days( as per the
test)and appt. date is informed
Pt. arrives for the invstgn on the appt. day
after Billing
Check whether the Pt. followed the correct
preparation chart or not
No
Did the Pt. follow
the preparation
properly?

Ask the Pt. to come back
with proper preparation



10
Yes
Pt is sent for invstgn after taking
informed consent
Inform the patient when they will get
their report
All critical reports are informed verbally
by the radiologist to the treating
consultant Immediately
Patient is instructed to have food as
per their consultant advice.
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
Viii . U.S. Scan procedures
Ultra sonogram (Abdomen):
Doctor prescribes the test
Pt. has to come with fasting for
a minimum of 4 hours
Before going for the test the Pt. is
required to have full bladder for which
the Pt. need to consume enough
amount of water
Before taking the Pt. for the invstgn
check for the satisfactory Pt.
preparation conditions
No
Yes
Is the Pt.
having full
bladder?
Pt. has to consume more
amt. of water and wait till
the bladder is full
Pt. is sent for investigation
Radiologist do the scan and give their
findings to typist, reports are generated
and dispatched within 30 Minutes.
11
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
ix. Ultrasound Transvaginal Scan
Doctor prescribes the test
While prescribing the test, doctor
specifies the day on which the test is
to be done and to take appointment
on the particular day
Pt. will come to get an
appointment and comes on that
date for the test to be done
Before taking the Pt. for invstgn check
whether the Pt.’s bladder is empty or not
and inform Pt. about the scan
No
Is the Pt.’s
bladder
empty?
Pt. has to empty the
bladder and then go for
invstgn
Yes
Pt. is sent for investigation
Reports are generated and
dispatched within 30
Minutes.
12
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
x. Report Generation:
After the Investigation, the concerned radiologist
prepares the report in writing in the radiology test
reporting form and rechecks the same.
No
Yes
Is there any
corrections?
Concerned Radiologists signs the
report along with the time and
date
Report is corrected
Report is attached with the films
& Reports are dispatched
The report along with the X-Ray
test requisition slip is forwarded.
OP – Patient/Relatives collect
the report from Radiology
Department Reception
IP – Inpatients reports are
dispatched to the specific
inpatient ward
13
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
xi. MRI: Magnetic Resonance Imaging:
MRI Scanning
Need for MRI prescribed by the Doctor. MRI requisition form filled by the treating
consultant clearly indicating the “part” and “compatibility status”.
Patient along with the MRI requisition form arrives at the
department. For inpatients an staff nurse/ward attendant
accompanies the patient to the MRI room.
No
Details mentioned in
the requisition form
entered in the MRI
register
Yes
Does the
patient need
preparation?
Patient is informed
about the preparation
to be taken. Time and
date for next
appointment is fixed.
Patient is instructed
to remove any
metallic articles and
change
Patientthe
is gown
Patient is sent for
MRI investigation in
the Gantry Room
14
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
F. Policies of the Department:
1. The Radiology Department operates within all applicable legislation, regulations and
Registration requirements.
2. All laws, regulations, directives, guidelines and registration requirements of Atomic
Energy Regulatory Board (AERB) & Health & Family Welfare Office, UttarPradesh
will be met and followed.
3. The hospitals Radiology Department have a valid and current Radiology AERB
Registration & Valid Approvals issued by the District Health & Family Welfare Office,
Uttar Pradesh department, which will be posted in public view.
4. All staffs will be provided with Thermo luminescent Dosimeter to measure (Radiation
received during working hours) Occupational exposure
5. All required records will be maintained by the Radiology Department.
G . Registration certificates:
i.
AERB layout Approval
ii. Form B – from District Health & Family Welfare Office .
H. Acts: The Department follows and operates strictly at par wit the regulations stated in the
following Acts :
 PNDT Act 1996
 AERB Safety code No:AERB/SC/MED-2(REV-1)2001
 Atomic Energy Act 1962
 Radiation protection Rules 1971
 Radiation Surveillance Procedures for Medical Applications of Radiation,1989
 The Bio-Medical Waste ( Management and Handling) Rules,1998
Dr. Ram Manohar Lohiya Hospital’s Department of Radiology complies with the following Regulatory
requirements for Medical X-Ray installation in India :

Safety Layout Approval from Atomic Energy Regulatory Board

Carry out Quality Assurance Performance Test of the x-ray unit yearly

Employ qualified Staff

Provide Personnel monitoring badges for all staff members associated with the
operation of x-ray machines

Comply with AERB Safety code No:AERB/SC/MED-2(REV-1)2001
15
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
I. Reporting Critical Results:
The below Mentioned Diagnosis (Critical Reports) will be informed to the treating
consultant immediately after the procedure:
i. Ectopic Pregnancy
ii. Deep Vein Thrombosis
iii. Perforation
iv. Incomplete Abortion
v. Hemorrhage
vi. Infarct
vii. Fracture.
viii. Pneumothorax
ix. Obstruction
x. Vascular Injury
The Department of Radiology follows the following statutory guidelines for registration of the
Ultrasound scans machine for Antenatal scan:
1. Ultrasound Machine Purchased will be registered with Uttar Pradesh Health Department.
2. Form B will be issued by the health department after registration.
3. A Registration number will be allotted to the radiology department in form B.
4. Statutory requirements are as follows:
a. Form B should be displayed in the ultrasound scan room.
b. Posters from the Health department (in local language) should be displayed in the
ultrasound scan room. Contents of the display are as follows:
i. Sex determination is ILLEGAL board should be displayed in English & local
language in OPD and in the department.
c.
Scanned Patient details should be preserved for 2 years from the date of Scan.
d. PNDT act copy to be kept in the department.
16
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
e. Consent forms F & G should be taken from the Patient before doing Antenatal
checkup.
f.
Total number of Antenatal Scans done should be sent to the following every month
on or before 5th through Register post to the District Health officer .
g. Xerox copy of the same should be filed and preserved in the department.
J. Quality Control: The main objective of quality control is to enhance the quality of x-ray/results by
checking the precision, accuracy and consistency of tests done.
Validation of examination procedure technically and clinically will be done by qualified and well
trained radiologist.
Quality Assurance is done with the following monitoring
a. Tracking Turn around time and waiting times
i.
Methodology: turn around time is tracked by manually tracking the in and
out time of the patient for each modality in the department
ii.
A suitable sample ( 7 days ) will be taken for this study.
b. Grading of x-ray films is done by the Radiologist
i.
Grading of X-ray films is done by the following criteria

Positioning
-
1

Artifacts.
-
1

Exposure factors
-
1
ii.
Grading - scores

Total score of 3 for each Patient to be documented for x-rays.

In case the quality is graded 1, x-ray to be repeated on Radiologist
opinion and more care to be taken during repeat x-ray.

Grading score should not be less than 90%.

Below 90 % reason should be evaluated & discussed with radiologist
and to be rectified immediately.
c.
Reject rates for films:
It should not be less than 3% of the Monthly consumption.
The Quality Assurance Manual of the department ( Ref N0 RML/QAM/01 ) can be referred for further
details.
17
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
Confidentiality of Reports : Confidentiality of patients and their test reports are ensured through the
following :
1. In the course of Performing work responsibilities all information with regard to patient, their
family, their physician and / or the hospital is kept confidential.
2. All the staff of the department are cautioned not to discuss any such information with others.
3. Personnel are expected and ensured to conduct themselves with professional dignity at all
times.
4. Radiologist are the only persons authorized to inform reports to the doctors.
K. Patient Education and Safety :
a. All patients are welcomed and explained about the process of the diagnostic
investigation in detail before starting the process.
b. All Patient are explained when and how their reports can be collected.
c.
While undergoing the investigation, all necessary precautions related to patient
safety is explained & followed.
d. Special care is taken while undergoing Investigations of infants/neonatal and
Geriatric patients. The parent / next to the kin of such patients are kept informed of
the process before investigations are started.
e. Attention of the patient/ customers will be drawn to the hygiene and safety aspects
before undergoing the Investigation.
f.
Consent will be taken whenever required in the appropriate forms.
g. All necessary steps will be taken to reduce /minimize /eliminate discomfort /pain
while conducting the Investigation.
h. In the course of performing work responsibilities all information with regard to
patient, their family, their physician and / or the hospital is kept confidential. The staff
of the department are cautioned not to discuss any such information with others.
18
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
L. Reporting of Imaging Test Results:
a. All reports of imaging test (except MRI) conducted before 1230 noon will be
dispatched to the front office of the department ( for OPD cases) or to the respective
inpatient wards (for IPD cases ) before 1400 hrs on the same day.
b. All test reports (except MRI) conducted after 1230hrs will be dispatched to the front
office of the department ( for OP patients) or to the respected inpatient wards ( for IP
patients) before 10 :00 hrs in the morning the next day.
d. Reports of all MRI scans done for OP will be dispatched next day morning
before 10:00 hrs in the morning.
e. Reports of MRI scan done for IP before 1300 hrs will be dispatched to the respective
inpatient wings prior to 1500 hrs on the same day .Reports of MRI scans done for IP
after 1300 hrs will be dispatched to the respective inpatient wings next day mornng
before 10 :00am
f. All critical reports are verbally informed to the concerned consultant immediately by
the Radiologist.
g. In case of any unavoidable delay, patients are kept informed for the reason for the
delay and by what time the investigations/delivery of reports are likely to be completed.
h. Any patient query regarding the reports will be dealt with immediately and clearly
explained, and further consultation arranged.
i. No test results are given to Patient verbally or over telephone .
j. Patient Reports are to be treated as completely confidential.
19
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
M. Turnaround time for reports:
a. X rays :
1. All reports of imaging test conducted before 12:30 noon will be dispatched to the
front office of the department ( for OPD cases) or to the respective inpatient wards
(for IPD cases ) before 1400 hrs on the same day.
2. All test reports conducted after 12:30hrs will be dispatched to the front office of the
department ( for OP patients) or to the respected inpatient wards ( for IP patients)
before 10 :00 hrs in the morning the next day.
b. Ultrasound: 30 Minutes after the scan
c.
MRI scan:
1. Reports of all MRI scans done for OP will be dispatched next day morning
before 10:00 hrs in the morning.
2. Reports of MRI scan done for IP before 1300 hrs will be dispatched to the
respective inpatient wings prior to 1500 hrs on the same day .Reports of MRI scans
done for IP after 1300 hrs will be dispatched to the respective inpatient wings next
day morning before 10 :00am.
d. Reporting of Emergency Cases:
1. In case of an emergency report, the radiologist will see the film and give a verbal
report to the referring consultant by phone.
2 . If the patient is referred or wants to go to some other hospital (on request or against
medical advice), Reports will be generated within 30 minutes (provided it is during
Radiologist’s office hours & if there is no emergency ultra sound scanning).
20
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
N. Criteria for Fixing of Appointments:
i.
According to “First Come First Serve” basis for routine X-ray
investigations.
ii.
According to the number of patients available on that particular day for the
iii.
investigation.
iv.
Iii. According to the availability of the radiologist (for the special
investigations)
v.
Depending on the time gap required for the preparation
vi.
Considering the patients existing health conditions.
vii.
Ultra sound scan – Appointment is given in 30 Minutes Interval.
Please note that even in case of given appointments patients from the critical care areas of
the hospital like the Emergency Department ,OT and other patients requiring emergency
imaging investigation etc are given priority for all procedures.
O. Maintenance of Equipment:
1. Guideline Instructions : General
a. All staff will clean the Machine in their Posted unit. Staff will conduct daily check on its
working condition daily & do regular warm up. Shutdown of machine should be done
after working hours.
b. Night Shift person is responsible for the machine till the handover to the next day
Morning shift person.
c.
Never keep any fluids over or near equipments.
d. Monitor Housekeeping staffs during cleaning mainly with wet mops.
e. Monthly cleaning record should be maintained for all equipments in Instrument History
card.
f.
In case of continuous power fluctuation shut down all the Machines, till proper power
supply is observed.
g. In daily Briefing Working condition & Breakdowns of machine should be handed over
without fail.
21
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
2. Infection control:
a. Ultrasound probes should be cleaned for each patient.
b. Machines should be cleaned with Antiseptic Solution after handling Road Traffic
Accident & Infectious patients.
c.
Mobile Machines shifted to Operating room and Intensive care units, wheels & area
in contact with patients should be cleaned with disinfectant solution before and after
use of the machine.
3. Breakdown management:
a. During breakdowns shutdown and restart the unit, check all Input & cables for loose
connections. In case this fails, complaint should be logged into Instrument History
Card and Work order should be raised and given to the Biomedical In charge
mentioning the Machine Name, time of breakdown.
b. The Biomedical engineer will inspect the machine & take necessary action as per
their protocol.
c.
It is the duty of the Radiographer to inform the Head of the Department of Radiology,
Registration Counter ,ED , ICCU and other patient care areas the breakdown time
and follow up on rectification till its working time every 12 Hours the status of the
breakdown .
d. In case of Major Breakdown the Chief Medical Superintendent should be informed.
e. After rectification service report is received and filed & the same is entered in
Instrument History Card.
f.
Incident Report is raised for all Breakdowns more than 24 hours.
22
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
P.
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
The training of Departmental Staff : The training of staff (for both existing and new staff) is
of utmost importance to prepare professionals who have high specific knowledge in their
area and who could give the best quality of care to their patients. Therefore training in
Radiology is a very complex and difficult task mainly due to wide spectrum of radiological
applications in the total care process and variety of imaging modalities .Hence the
department lays special emphasis on training of the employees to acquaint them with the
knowledge and skill pertaining to their job. The approach to training of the staff adopted by
the department is as follows:
a. One week department Induction for every new employee (Transferred or Fresh
Recruit) joining the department.
b. One week department Induction to learn department policy & procedures and safety
training will be conducted for the new employee in the department.
c.
Training in Safety procedures to follow if equipment malfunction occur.
d. Training relating to the operation of any new equipment is given prior to the usage of
the equipment by company engineers to ensure its proper and safe handling.
e. All professional personnel are expected to be competent and proficient in all
performance of all procedures by the end of the training program.
f.
The training program will serve as verification of initial personnel competency and
ability to satisfactorily perform patient care and services.
g. Those areas felt to be requiring additional focus by the trainee will be identified as
personal goals, for which improved performance will be emphasized.
h. All staffs should attend and do regular training.
23
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
Departmental Orientation programme for the new employees (Fresh recruit or transferred
emphasizes on the following :
a. Overview to various equipments operated by the department in detail
b. Radiation safety & quality Assurance Practices
c.
Basic unit maintenance and trouble shooting
d. Documentation and record keeping.
e. PNDT act & Maintenance of records is explained
f.
Uses of TLD badge & how to use Hand out given.
g. Turn Around time for different types of cases ( Normal , Urgent etc).
h. Safety procedure and Policy of the department.
i.
Various forms and Reporting formats used by the department
Q. Departmental Inventory Management:
The responsibility for proper management of the departmental inventory rests with the
radiographers.
a. A stock book for the various items including the medicines used by the department is
maintained.
b. Physical verification of the stock is done every alternate days by the radiographers.
c. Replenishment of stock is done using the appropriate indent request book.
d. All medicines subject to expiry are returned to the pharmacy store and indent request for fresh
stock is placed.
24
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
R. Out Sourcing of Imaging test not available in the hospital :
1. Computerized Tomography Scan.
2. Mammography.
3. Color Doppler Studies.
4. BMD
5. DSA
6. PET.
25
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
S. REPORTING FORMAT FOR DAILY/MONTH STATISTICS:
The Radiographers are responsible for completion and submission of the daily statistic to the Head
of the Department of Radiology in the specified format .The Head of the Department of Radiology
monitors the performance of the department and forwards a monthly report about the same to the
Chief Medical Superintendent.
Format for Reporting Daily Activities ( To be filled by the Radiographers)
IP
DATE
XR-FILM
USG
ECHO
MRI
Total procedures
Total patients
OP
DATE
XR-FILM
USG
ECHO
MRI
Total Procedures
Total patients
26
Manual Of Operations
Dr. Ram Manohar Lohia
Combined Hospital , Lucknow
Quality Operating
Process
Document No :
RML/RAD/01
Manual of Operations
Department Of Radiology
Date of Issue :
15/1/2008
Monthly- Format ( To be submitted to the CMS )
Dr. Ram Manohar
Lohiya Hospital
RADIOLOGY
DEPARTMENT
MONTHLY
STATISTICS
TOTAL
MONTH
T.
X-RAY
No. of xrays/technician/day
USG
No. of MRI
scans per
day
USG per
day
QUALITY PLAN
Quality Indicator:
a. Indicator : Turn around time for reports
Date
X-ray
No.
Pt. Name
MRN
Procedure Done
Received
request
time
Patient taken
for
procedure
Duration
In Minutes
b. Benchmark:
i.
Other quality initiatives:
Reject rates for radiology films
Forms Documents and Stationary
j.
Patient related forms
S No:
1
2
Form
Request Form with consent for procedures
F & G consent form for OBG ultrasound
k. Registers
S No:
1
2
3
Form
Daily entry registers for all procedures
Outsourcing register
Pharmacy consumable register
27
Manual Of Operations