RAD.01 RAD.01.1 RAD.01.2 RAD.01.3 DIAGNOSTIC RADIOGRAPHIC EXAMS AVAILABLE AT GANNETT PURPOSE The purpose of this policy is to list all of the radiographic exams available to be performed at Gannett. ASPECT OF CARE Radiological service POLICY The following list outlines all of the diagnostic radiologic exams available at Gannett. 1. ABDOMEN AP SUPINE & UPRIGHT 2. ABDOMEN AP SUPINE(KUB) 3. AC JOINTS BILATERAL AP ERECT WITH & WITHOUT WEIGHTS 4. ANKLE AP, OBLIQUE AND LATERAL 5. CERVICAL SPINE AP, ODONTOID, OBLIQUE, LATERAL (FLEXION & EXTENSION IF REQUESTED) 6. CHEST PA (INSPIRATION AND EXPIRATION OR DECUBITUS IF REQUESTED) & LATERAL 7. CLAVICLE AP 20 UPSHOT AND AP 8. COCCYX/SACRUM AP 25 CEPHALAD & 10 CALEDAD DOWNSHOT & LATERAL 9. DORSAL SPINE AP & LATERAL 10. DORSOULUMBER SPINE AP & LATERAL 11. ELBOW AP, OBLIQUES & LATERAL 12. FACIAL BONES CALDWELL, WATERS, TOWNE, LATERAL & SMV 13. FEMUR AP & LATERAL 14. FINGER PA, OBLIQUE & LATERAL 15. FOREARM AP & LATERAL
16. FOOT AP 15 CEPHALAD, OBLIQUE AND LATERAL 17. HAND PA & OBLIQUES & LATERAL 18. HIP AP PELVIS & FROG LATERAL 19. HIP (CHRONIC PAIN SERIES) AP PELVIS, FROG, 30% CEPHALAD FROG LEG LATERAL 20. HUMERUS AP & LATERAL 21. KNEE PA, TUNNEL, LATERAL & MERCHANTS 22. LUMBAR SPINE AP & LATERAL 23. LUMBOSACRAL SPINE AP, OBLIQUES AND LATERAL 24. MANDIBLE PA & AXIOLATERALS 25. MASTOIDS STENVERS, LAWS & TOWNE 26. NASAL BONES WATERS & LATERAL 27. OC CALCIS OBLIQUES, LATERAL & 45 CEPHALAD TANGENTIAL 28. PARANASAL SINUSES CALDWELL, WATERS, LATERAL & SMV 29. PELVIS AP 30. RIBS AP(ABOVE & BELOW DIAPHRAGM) AND OBLIQUE OF AFFECTED SIDE 31. SACROILIAC JOINTS 25 CEPHALAD AP & OBLIQUES 32. SCAPULA AP & LATERAL 33. SHOULDER AP, OBLIQUE, & AXILLARY 34. SKULL AP, LATERAL OF AFFECTED SIDE TOWNE & SMV 35. STERNOCLAVICULAR JTS OBLIQUES 36. STERNUM OBLIQUE & LATERAL 37. TIBIA & FIBULA AP & LATERAL
38. T.M. JOINTS LATERAL(OPEN & CLOSED MOUTH) BILATERAL 39. TOE PA, OBLIQUE & LATERAL 40. WRIST PA, OBLIQUE & LATERAL, (NAVICULAR IF REQUESTED RAD.01.4 RAD.01.5 RAD.01.6 RAD.01.7 DEFINITIONS n/a RESPONSIBLE DEPARTMENTS Radiology POLICY n/a REVISION HISTORY May 2010, March 2012, August 2013
RAD.02 RAD.02.1 RAD.02.2 RAD.02.3 RAD.02.3.1 RAD.02.3.2 RAD.02.3.3 RAD.02.3.4 RAD.02.3.5 RAD.02.4 RAD.02.4.1 RAD.02.5 RAD.02.6 RAD.02.6.1 X-RAY REQUISITIONS FROM OFF-SITE PRACTICIONERS PURPOSE The purpose of this policy is to ensure that patients will have an appropriate and legal request for an x-ray exam performed at Gannett. ASPECT OF CARE Radiological service POLICY Gannett will provide diagnostic radiological service as required for the examination and treatment of Gannett patients with the least possible radiation dose and discomfort to the patient. Gannett will only accept x-ray orders from persons defined by the NYS Department of Health as a professional practitioner, per Chapter I Part 16 of the State Sanitary Code. At Gannett, this gives an MD, DO, NP, or PA the authority to order x-rays. RNs may order x-rays of the chest for administrative reasons, i.e., +ppd., visa requirements, etc. and may order x-rays of the wrist distally to fingers or ankle distally to the toes; to expedite patient care--under the direct order of a professional practitioner. Faculty and staff presenting with orders from off-site clinicians must be informed that our arrangement with the radiologists is that they will only read Gannett films ordered by Gannett. Any other films that they read are done on a fee-for-service basis through Cayuga Medical Center. In most cases, nonstudents with off-site x-ray requisitions need to be referred to the hospital. It is important to be aware that in cases of a disability or other unusual circumstances, there is some flexibility in this policy and the judgment of the Associate Directors for Medicine or Nursing and Clinical Support Services, or other administrator should be sought. DEFINITIONS Professional Practitioner Any person licensed or otherwise authorized under the New York State Education Law to practice a professional practice medicine, dentistry, podiatry, osteopathy, or chiropractic. RESPONSIBLE DEPARTMENTS Radiology PROCEDURES Requisition from Off-Site Practitioners RAD.02.6.1.1 Requisitions from off-site clinicians for students will be honored if they contain the following:
(a) Patient s name (b) Part to be x-rayed (c) Diagnosis or clinical findings (d) Clinician s name and signature RAD.02.6.1.2 A copy of the requisition is to be scanned into the medical chart. RAD.02.7 REVISION HISTORY May 2010, February 2011, September 2011, March 2012, August 2013
RAD.03 RAD.03.1 RAD.03.2 RAD.03.3 RAD.03.4 RAD.03.5 RAD.03.6 RAD.03.6.1 PATIENT FLOW PURPOSE The purpose of this policy is to maintain safe and efficient clinic flow. ASPECT OF CARE Provision of timely clinical support services POLICY Safe and efficient patient flow will be a priority. Procedures should be in place to optimize patient flow. DEFINITIONS n/a RESPONSIBLE DEPARTMENTS Radiology PROCEDURES Requests and Referrals RAD.03.6.1.1 Requests are entered into Point and Click system by an attending clinician with specific clinical findings entered into the note area as well as related diagnosis. RAD.03.6.1.2 Emergency patients or possible TB patients should be referred via phone call by the floor nurse or receptionist and the technologist will meet the patient in Level 2 waiting room. RAD.03.6.1.3 The technologist must be notified in advance and extra time must be allowed if a decubitus chest film is requested. RAD.03.6.2 Patient Flow RAD.03.6.2.1 The patient will present to Radiology and check in with the receptionist, who will alert the technologist. In the absence of the receptionist, the patient will ring the x-ray doorbell to alert the technologist. RAD.03.6.2.2 Very sick, injured, or light-headed patients should be escorted by a nurse to Radiology in a wheelchair. RAD.03.6.2.3 When the radiographic exam is complete, the patients will be instructed to go to their referring clinician s level and check in with the receptionist. RAD.03.6.2.4 Staff members who escort patients to Radiology by wheelchair should wait until the patient s exam is completed and escort the patient back to
the appropriate level. RAD.03.7 REVISION HISTORY May 2010, February 2011, September 2011, March 2012, August 2013
RAD.04 RAD.04.1 RAD.04.2 RAD.04.3 RAD.04.4 RAD.04.5 RAD.04.6 RAD.04.6.1 PATIENT RADIOGRAPHY PURPOSE The purpose of this policy is to outline the protocols for order-processing. ASPECT OF CARE Safe and efficient patient flow POLICY n/a DEFINITIONS n/a RESPONSIBLE DEPARTMENTS Radiology PROCEDURES Conducting the Exam RAD.04.6.1.1 Processing Clinician Orders (a) Technologist will locate patient s order in Point and Click (b) Check information for accuracy and omissions (c) Right-click or double-click accession order RAD.04.6.1.2 Go to RIS to select patient schedule. Order should then go to DR3500. RAD.04.6.1.3 Prepare Patient for Exam (a) If patient is female, ask if pregnant (b) Evaluate patient s condition as to how the exam is to be satisfactorily performed with the least possible discomfort and radiation dose to the patient. (c) Instruct patient for the procedure and attire (or lack of it) for exam. RAD.04.6.1.4 Performing the Exam (a) Position patient for appropriate views needed to demonstrate the anatomy in question. Place R (ight) or L (eft) lead markers on film to identify anatomy (markers also identify technologist by their initials). (b) Shield patient s gonadal areas which are not overlying the area in question with lead. There should be evidence of collimation to the specified body part according to the New York State Department of Health. (c) Set technique necessary to penetrate the part to be examined, and get the best possible detail on the image with the least possible radiation dose to the patient.
(d) Instruct the patient on holding breath, holding still, etc. (e) Take the exposure. RAD.04.6.2 RAD.04.6.3 RAD.04.6.4 RAD.04.6.5 RAD.04.7 Accept or reject images. Because of the absence of a radiologist on-site the technologist must assure that the quality of the exam is optimum and repeat if necessary. This then sends images to the PAC s. From RIS, select exam done. This alerts Point and Click billing. Send any pertinent information via RIS to radiologist for his interpretation of the films daily (M-F). The radiologist will dictate and sign reports from RIS. Transcribe reports by entering into RIS. REVISION HISTORY May 2010, February 2011, October 2011, March 2012, August 2013
RAD.05 RAD.05.1 RAD.05.2 RAD.05.3 RAD.05.3.1 RAD.05.3.2 RAD.05.3.3 RAD.05.4 RAD.05.5 RAD.05.6 RAD.05.6.1 RAD.05.6.2 RAD.05.6.3 RAD.05.6.4 RAD.05.6.5 RADIOGRAPHY OF PATIENTS WHO ARE OR MAY BE PREGNANT PURPOSE The purpose of this policy is to minimize the possibility of injuring an unborn fetus by the use of ionizing radiation during an x-ray exam. ASPECT OF CARE Patient safety POLICY When the presence of pregnancy is unclear, a positive or negative indication shall be ascertained by pregnancy test before proceeding with any exam. Women of child-bearing age and individuals under the age of 18 shall not hold patients during radiographic exposures under any circumstance. No person shall be regularly employed to hold patients or film during radiographic exposures. DEFINITIONS n/a RESPONSIBLE DEPARTMENTS Radiology PROCEDURES A sign shall be conspicuously posted in the Radiology waiting area, Radiology changing area, and Radiology exam room which instructs all female patients, to inform the technologist of the possibility of pregnancy. The attending clinician and the technologist shall ask each female patient of child bearing age if there is any possibility of pregnancy. Radiography of the lower back, abdomen or pelvis shall be confined to the 10 days after onset of menses, or after administration of Implanon, Depo-Provera, or an IUD in women of child-bearing age. If the patient states there is no possibility of pregnancy, radiography of other body parts may be done at any time provided the exposure is limited to the particular area of interest by collimation and shielding. Patients Who Are or May Be Pregnant RAD.05.6.5.1 For patients who are or may be pregnant, the clinician is called to determine the urgency of the exam and whether it can be postponed until after delivery or onset of menstruation, or whether it should be
performed with maximum lead shielding. RAD.05.6.5.2 If the exam ordered is that of lower back, abdomen or pelvis it should be avoided completely, if possible. RAD.05.6.5.3 In either case, the clinician is to note this in the patient s chart. RAD.05.6.6 RAD.05.7 Any occurrence which requires the holding of a patient shall be documented on an Occurrence Report and submitted to Administration within 24 hours. REVISION HISTORY May 2010, February 2011, September 2011, March 2012, August 2013
RAD.06 RAD.06.1 RAD.06.2 RAD.06.3 RAD.06.3.1 RAD.06.3.2 RAD.06.3.3 RAD.06.3.4 RAD.06.4 RAD.06.5 RAD.06.6 RAD.06.7 PATIENT SHIELDING PURPOSE The purpose of this policy is to minimize the possibility of unnecessary radiation exposure to radiosensitive areas of patients having x-ray exams. ASPECT OF CARE Radiation protection for patients having x-ray exams POLICY The primary beam will be limited to the area being examined. The Radiology Department will use the least amount of radiographic exposure to produce radiographs of diagnostic quality. Gonadal shielding of not less than 0.5 mm lead equivalent shall be used for all patients during radiographic procedures in which the gonads are not in the area of interest. Collimation shall be used for all thoracic and thoracolumbar spines. DEFINITIONS n/a RESPONSIBLE DEPARTMENTS Radiology PROCEDURES n/a REVISION HISTORY May 2010, February 2011, September 2011, August 2013
RAD.07 RAD.07.1 RAD.07.2 RAD.07.3 RAD.07.3.1 RAD.07.3.2 RAD.07.3.3 RAD.07.4 RAD.07.5 RAD.07.6 RAD.07.6.1 RAD.07.6.2 PERSONNEL RADIATION PROTECTION PURPOSE The purpose of this policy is to protect the Gannett radiation workers from unnecessary exposure to ionizing radiation during the course of their job duties. ASPECT OF CARE Radiation protection for personnel POLICY All personnel shall be provided with instructions and equipment, as required to maintain their safety. Women of child-bearing age and individuals under the age of 18 shall not hold patients during radiographic exposures under any circumstance. No person shall be regularly employed to hold patients or film during radiographic exposures. DEFINITIONS n/a RESPONSIBLE DEPARTMENTS Radiology PROCEDURES Area badges have replaced personnel monitoring devices. The badge is in the Control booth in the X-ray room. The control badge is located in the Radiology office. The badges are evaluated on a quarterly basis, and Cornell University Office of Environmental Health and Safety keeps the records Holding Patients and/or Films RAD.07.6.2.1 When a patient must be held in position during exposure, mechanical restraining or supporting devices shall be used. RAD.07.6.2.2 Non-occupationally exposed individuals should hold patients or films only when clinically necessary under extreme conditions. (a) Such individuals shall wear protective gloves having at least 0.5 mm lead equivalent and a protective apron of at least 0.25 mm lead equivalent (b) These individuals shall keep all parts of his body out of the useful beam RAD.07.6.3 Any occurrence which requires the holding of a patient shall be documented on an Occurrence Report and submitted to Administration within 24 hours.
RAD.07.7 REVISION HISTORY May 2010, February 2011, September 2011, March 2012, August 2013
RAD.08 RAD.08.1 RAD.08.2 RAD.08.3 RAD.08.4 RAD.08.5 RAD.08.6 RAD.08.6.1 RAD.08.6.2 RAD.08.7 STAT INTERPRETATIONS PURPOSE The purpose of this policy is to outline the procedure for obtaining a stat radiologist s interpretation of a patient s Gannett films when there is medical necessity. ASPECT OF CARE Stat interpretation of a patient s Gannett films POLICY A Gannett clinician may request a stat reading when it is imperative to have a radiographic diagnosis immediately. DEFINITIONS n/a RESPONSIBLE DEPARTMENTS Radiology PROCEDURES Monday through Friday, the Gannett clinician should make the request to the technologist who will then call CMC (Cayuga Medical Center) or CCC (Cortland Convenient Care) Radiology Department to notify the Radiologist of the situation. The Radiologist will be given a phone number to which the referring clinician can be called directly with the interpretation. After hours and Saturdays, the clinician should call the Radiology department at CMC or CCC and speak to the Radiologist to request a stat interpretation. REVISION HISTORY May 2010, February 2011, September 2011, March 2012, August 2013
RAD.09 RAD.09.1 RAD.09.2 RAD.09.3 RAD.09.3.1 RAD.09.3.2 RAD.09.3.3 RAD.09.4 RAD.09.5 RAD.09.6 RAD.09.6.1 RAD.09.6.2 RELEASE OF IMAGES FROM THE RADIOLOGY DEPARTMENT PURPOSE The purpose of this policy is to ensure that Gannett films on a particular patient are available when needed. ASPECT OF CARE Radiological service POLICY Patient film files prior to January, 2008 will be maintained at Sywest Medical Technologies in East Syracuse NY. Files post-january, 2008 will be maintained on Gannett s PAC s system. All radiographic images, reports and other related materials are confidential and the information in them cannot be disclosed without the written consent of the patient or his/her representative. Title 10 (HEALTH) of NY codes, Rules and Regulation; 751.9(n) & (o). All films will be copied onto a CD. There is no charge for the first CD. Second and subsequent CDs will be copied at a cost of $5.00. DEFINITIONS n/a RESPONSIBLE DEPARTMENTS Radiology PROCEDURES Have the patient sign an Authorization for Release of Health Records. Producing Images RAD.09.6.2.1 For images prior to January 2008: (a) Contact Sywest Medical Technologies in East Syracuse, NY, noting the date and x-ray number on the required films to be certain the correct exam is being obtained. (b) Sywest will pull the patient s file envelope, remove the requested films, and scan the films into Gannett s PAC s system. (c) Gannett Technologist will copy the images onto CD from PAC s and make a copy of the radiologist report. RAD.09.6.2.2 For images post-january 2008: Gannett Technologist will copy the images onto CD from PAC s. RAD.09.6.2.3 All CDs will have a Quick Reference Card for Using CDs created by
Kodak Carestream PACS CD Direct Suite. RAD.09.7 REVISION HISTORY May 2010, February 2011, September 2011, August 2013
RAD.10 RAD.10.1 RAD.10.2 RAD.10.3 RAD.110 RETENTION OF RADIOGRAPHIC FILES PURPOSE The purpose of this policy is to ensure that retention of Gannett films follow Department of Health guidelines for the management of protected health information. ASPECT OF CARE Radiological service and management of protected health information POLICY RAD.10.3.1 Gannett will retain x-rays following the same Department of Health guidelines (Title 10: Rules and regulations Feb. 14, 1996 PART 751 ORGANIZATION AND ADMINISTRATION Sec.751.7 (j)) for the retention of all protected health information. RAD.10.3.2 RAD.10.3.3 RAD.10.4 RAD.10.5 RAD.10.6 RAD.10.6.1 RAD.10.6.2 RAD.10.6.3 RAD.10.6.4 X-rays will be retained for at least six years after the last date of service rendered to a patient. In the case of a minor, x-rays will be retained for at least six years after the last date of service rendered or for three years after the patient reaches the age of 18, whichever is longer. (see Section 415.21) DEFINITIONS n/a RESPONSIBLE DEPARTMENTS Radiology PROCEDURES X-rays filed prior to January 2008 will be maintained at Sywest Medical Technologies in East Syracuse, NY and retained for 6 years after the last examination, then pulled and disposed of by Sywest. X-rays taken on and after January 2008 will be stored on PAC s, with backup indefinitely. Asbestos and Workmen s Comp exposure x-rays will be marked as such and kept indefinitely. X-rays of Minors RAD.10.6.4.1 Folders of minors are marked as such with age (upper right hand corner of film jacket) at the time of the X-ray and noted on film jacket. RAD.10.6.4.2 These will be maintained until the patient is 21 years old.
RAD.10.6.5 RAD.10.7 For Worker s Compensation, a folder will be marked as Worker s Comp and be maintained for 30 years. REVISION HISTORY May 2010, February 2011, September 2011, August 2013
RAD.11 RAD.11.1 RAD.11.2 RAD.11.3 RAD.11.4 RAD.11.5 RAD.11.6 RAD.11.6.1 CENSUS PURPOSE The purpose of this policy is to monitor the volume of testing performed and evaluate trends. ASPECT OF CARE Utilization tracking POLICY A census of all x-ray exams will be performed monthly. DEFINITIONS n/a RESPONSIBLE DEPARTMENTS Radiology PROCEDURES A census of all exams performed each month is tallied from Point and Click report. RAD.11.6.1.1 The same month of the previous year s census is recorded for comparison. RAD.11.6.1.2 The film repeat rate is also calculated for that month by taking the total repeated films from the DR3500 x-ray machine. Look under Keyop, administrative functions, and then reject statistics. RAD.11.7 REVISION HISTORY May 2010, February 2011, September 2011, March 2012, August 2013
RAD.12 RAD.12.1 SERVICE AND MAINTENANCE INFORMATION RADIOGRAPHIC UNITS 1. The Kodak DR3500 is under warranty with Sywest Medical Technologies. 2. The following warm-up procedure is done to warm up the DR3500 (Room RAD.12.2 RAD.12.3 DAILY: MONTHLY: 1. The unit is turned on at console. Log on. 2. Go to utilities 1. Tube warm up, follow instructions on screen. 2. Detector calibration, follow instructions on screen 1. The next two tests must be done in sequence and take approximately 1hr to complete. 1. Dark Calibration, follow instructions on screen. 2. X-ray calibration, follow instructions on screen. ALL REQUIRED TESTING FOR STATE IS FOUND IN RADIOLOGY QA MANUAL
RAD.13 REFERENCE MATERIAL 1. RADIOGRAPHIC TECHNIQUE MANUAL Room 1 has automatic techniques entered into DR3500 computer. Manual techniques are posted in the room. 2. MERRILL S ATLAS OF RADIOGRAPHIC POSITIONING On the shelf above the radiologist s desk. 3. VARIOUS RADIOLOGIC PATHOLOGY AND DIAGNOSES BOOKS On the shelf above the radiologist s desk. 4. QUALITY ASSURANCE TEST STANDARDS BOOKS AND QI MANUAL Are kept in the workstation shelves. 5. THE CU CHEMICAL HYGIENE PLAN, NOTEBOOK OF MSDS SHEETS, AND CU RADIATION SAFETY MANUAL Can be accessed on the Gannett Intranet.