Radiology Department. Local Procedure

Transcription

1 Title: Radiology Department Local Procedure Procedure for requesting imaging procedures and sending out imaging reports Reference: Rad Author: Yvonne Shanks Date ratified: TBC Ratified by: Radiology Risk Meeting NB: If this document is printed into hard copy or saved to another location, you must check that the version number on your copy matches that of the local procedure control sheet. 1. Introduction The local procedure is provided to provide clarity around the internal requesting imaging and sending out imaging reports within the Radiology Department. This local procedure has been formulated after a process review in line with the Trusts Management for Diagnostic Testing Policy 1.1. Scope All Radiology staff Trust clinical staff 2. Definitions PAS Patient Administration System CRIS Radiology Information System 3. Procedure 3.1. The procedure applies to the following tests: CT MRI Endovascular Fluoroscopy Plain Film Ultrasound The following arrangements are detailed within the process: How the diagnostic test is requested (including how this is recorded) How the clinician treating the patient is informed of the results (including timescales and how this is recorded) How patient is informed of the result (including timescales and how this is recorded) Actions to be taken by the clinician (including timescales and how this is recorded) Page 1 of 7

2 3.2. How the diagnostic test is requested All imaging requests: CT / MRI / Endovascular/ Fluoroscopy/ Plain Film/ Ultrasound are handwritten using The Walton Centre Imaging request form All the handwriting on the form and the signature must be the same and be that of the referring clinician If a name sticker is used it must be attached to a blank form and then the request, clinical history and signature must be in the handwriting of the requesting clinician The form must be available, correctly filled in prior to the Imaging procedure in order for the examination to be justified Inpatients Inpatient CT/ MRI / Endovascular and Ultrasound requests must be discussed with a Neuroradiologist for justification prior to any appointment being agreed 3.4. CT and MR requests Co-ordinated with the individual departments and scanned on clinical urgency 3.5. Outpatients Outpatient requests are sent via the internal mail system or hand delivered to the Radiology department MRI requests Are entered onto the CRIS system A protocol sheet will be attached and the forms are placed in the to be vetted slot in the Radiology office Consultant Neuroradiologist will remove from slot (several times during the day) and protocol / justify request Protocolled forms will be returned to Diagnostic PAC team and then entered onto PAS system and updated on CRIS with correct examination Patient is then contacted for partial booking (either by phone or letter) CT requests Are entered onto the CRIS system and PAS system and if patient is at reception an appointment will be given immediately If form is received in mail then the request will be vetted and protocolled. Patient will be contacted for partial booking (as per MRI) Endovascular Page 2 of 7

3 3.8.1 Request form is protocolled by Neuroradiologist Copies of request forms are given to Diagnostic PAC team and the patient is contacted by phone or letter and appointment is booked Ultrasound Request forms are reviewed by a reporting radiographer/radiologist to protocol/justify the request and scanned according to clinical urgency All requests are entered onto CRIS. If an inpatient then the ward staff is informed by phone of the appointment. If the patient is an outpatient then the patient will be contacted for partial booking (as per MRI) Fluoroscopy Request form is protocolled by Neuroradiologist. Copies of request forms are given to Diagnostic PAC team and the patient is contacted by phone or letter and appointment is booked Plain Film Appointments are fully booked on receipt of request 4. Protocol to highlight and prioritise urgent reports Urgent imaging requests will be discussed by the referrer with a Neuroradiologist Any request identified as URGENT will be protocolled as such Following imaging the Radiographer will complete post processing on CRIS and identify the urgency of the report by changing the urgency field to 5 in event details This also applies to any imaging that is not protocolled as urgent but the Radiographer identifies as needing an urgent report following imaging When Radiologist logs onto CRIS the Radiologist must change priority order to search by urgency. Urgent imaging will then be highlighted at the top of the reporting list. The radiologist can also use the option to colour by urgency on the report info list Any imaging that has an urgent report or any unexpected findings will be identified to the radiology secretaries by the radiologist (this applies to either DD or VR). The radiology secretaries will print report and then inform referrers secretary that an urgent report has been issued and then fax a copy to relevant referrers secretary How the Clinician treating the patient is informed of the results Radiologist reports and verifies report on PACS / RIS Reports are batch printed on a daily basis ( Monday- Friday) by Radiology secretarial staff Reports are sent to the referring clinician via their secretary, on the day of printing (within Trust guidelines) Page 3 of 7

4 4.3.4 Reports are also available to view on Carestream Vue, immediately after verification by reporting radiologist A report can be copied to another consultant where there is shared care or treatment It is the responsibility of the referring clinician to ensure the report is acted on and the patient is informed within 3 weeks If a GP or an external clinician asks for information regarding a patients reports, then they should be referred to the consultant who is caring for the patient If there are any queries a Neuroradiologist should be contacted Radiology reporting turnaround times are stated within the Trust wide Policy for the Management of Diagnostic Testing. 5. How the patient is informed of the result The Diagnostic departments will assume responsibility for carrying out and reporting tests, and advising the patient how they should receive their results The referring clinicians will assume responsibility for informing all relevant parties of the results and any appropriate subsequent action. The referring clinician will inform the patient of the results within 3 weeks (refer to Trust policy for the Management of Diagnostic Testing ). 6. Monitoring See Appendix Reference/Supporting Documents Trust Organisation wide Policy for the Management for Diagnostic Testing Policy. 8. Review Annual review within the Radiology Risk Meeting (due date April 14). Page 4 of 7

5 Appendix 1 Risk Assessment Processes a. Process for requesting the diagnostic testing procedure b. How the clinician treating the patient is informed of the result, including timescales c. How patient is informed of the result (including timescales and how this is recorded) d. Actions to be taken by the clinician, including timescales e. Process for recording and monitoring points a to d (as above) a. Likelihood that processes fail 0-5% 6-25% 26-50% 51-75% % X X Please refer to Trust policy management of Diagnostic Testing Please refer to Trust policy management of Diagnostic Testing For processes with a failure risk >5% ONLY Risk identified in process Paper system, can be lost in transport Paper reports sent to referrer secretary Please refer to Trust policy management of Diagnostic Testing Please refer to Trust policy management of Diagnostic Testing Requests entered on CRIS Monthly turnaround reports Bi Annual audit Mitigation Majority hand delivered to department Electronic reports can be viewed on Carestream Vue Monthly report on radiology reporting turnaround times Bi Annual audit b. c. d. Page 5 of 7

6 Appendix 2 Monitoring Minimum requirement to be monitored How the diagnostic procedure is requested How the clinician treating the patient is informed of the result, including timescales How the patient is informed of the result, including timescales Action to be taken by the clinician, including timescales How minimum requirements c) to f) are recorded Frequency of monitoring Annual Please refer to Trust policy Process for monitoring Audit individual Non-Medical Risk Lead for Neuroradiology or nominated deputy individual/ group/ committee for review of results Neuroradiology Risk meeting individual/ group/ for development of any action plans Neuroradiology Risk meeting individual/ group/ committee for monitoring of any action plans and implementation Neuroradiology Risk meeting Section and page number in policy Page 6 of 7

7 Document Control Change Control Date Author Version Change Description / Reviewer Y Shanks 1.1 Update to ISO layout Document Status Draft Storage & Retrieval: Implementation: Service Shared Server Local Procedure Folders (Master copy and version history with Y Shanks) Circulate to all Departmental Staff. Page 7 of 7