Radiology Services

Civil Hospital Gurgaon Standard Operating Procedure Document No CH/GGN /Rad/9
No 13
RADIOLOGY SERVICES Date of Issue: 01-01-2016
1.0 POLICY
Hospital provides imaging services which are generally required with the scope of clinical
services offered by the hospital. The tests which are not available but required for clinical
management are outsourced as per policy of the hospital.
2.0 PURPOSE
• To effectively provide all radiology services as required by the scope of clinical services
of the hospital.
• To adhere with the quality of diagnostic techniques
• To avoid any mistake in managing the department and getting expected result on time.
• To establish an appropriate mechanism for transfer imaging patients throughout hospital.
• To have a defined time frame for each test.
• To have monitoring system for the same
• To take preventive and corrective action against preventable and correctable measure.
• To make available imaging reports to the patient with the defined time frame.
• To monitor the system to identify any gaps from hospital point of view.
• To take corrective and preventive action against preventable and correctable measures
• To Provide better clinical care to the patients
3.0 DEFINITION (IF ANY)

TAT: the interval between when a test is requested to the time the test results are available.
Critical: A test results beyond the normal variation with a high probability of a significant
increase in morbidity and/or mortality in the foreseeable future and requires rapid
communication of results for determination of intervention.
Read Back: The individual accepting the critical test result must record and then read back the
critical test result, in its entirety, to the reporter at the time the result is given.
4.0 ABBREVIATIONS (IF ANY)
TAT-Turnaround time
RSO – Radiation Safety Officer
IPD – Inpatient department
OPD – Out patient department
5.0 SCOPEImaging department, IPD, OPD, Emergency Department, Patient & Relatives
6.0 RESPONSIBILITYRadiology Department, Administration Department
7.0 DISTRIBUTIONRadiology Department, Administration Department, Safety Officer
Prepared By Issued By Approved By

No 13
8.0 PROCESS DETAIL
8.1 Legal & Other Requirements:

The imaging services complies with legal and other requirements like BARC clearance,
dosimeters, lead sheets, lead aprons, signage, display as per PNDT act, and reports to higher
authority etc. and the same are documented for information and compliance by all concerned in
the organization. The organization maintains and updates its compliance status of legal and other
requirements in a regular manner.
The organization also has an RSO (of level I)
8.2 FACILITY AVAILABLE

Following imaging services are provided in house by imaging department
• General Radiography
• Mobile radiography
• Mammography
• C-Arm
• Ultra Sound
• Magnetic resonance Imaging
8.5 Identification and safe transportation of patient to imaging services:

a. Identification of Radiology Patients
• All registered patients are given a unique identification no. OP/IP No

• The receipt given on submission of the bill has the details of the test to be performed and the
patients OP/ IP No
b. Safe transportation:
The hospital has a policy for safe transport of patient to and from the radiology department.
Patient is transported (internally) in a safe manner and is accompanied by a hospital staff.
• For stretcher bound patient – accompanied by Class IV or staff nurse

• For wheelchair bound / mobile patient – accompanied by Class IV
Following protocols are followed while transporting the patient:
• Reason for transportation is clearly explain to the patient /relative

• For stable patient attendant can accompany the patient while transportation
• For unstable patient nurse/Class IV as appropriate should accompany the patient while
transportation.
• Patients’ medical file is carried along with the patient if requested for.

No 13
8.6 Turn Around Time:

The test results for the Imaging tests performed in the hospital are available to the patient /
relatives / ward in-charge in the defined time frame.All patients are informed about the time of
reports dispatch at the time of procedure
1. Turnaround time for reports
a. X rays
I. No X-ray reporting is been done at Civil Hospital except for the MLC cases
II. OPD - Normally all films for X-rays done till 11:00am are handed over to patient on
same day after 1300 hours.
III. in patient s- For all X-rays done in OPD hours, X rays films are given to patients on
same day after 1300hrs, while the film for the X-rays done after 2 pm are given in 1
hour
b. Ultrasound: 30 Minutes after the scan
c. MRI scan:
I. All OPD scans done till 1400 hrs are dispatched after 1 day at 8:00 am
II. All IPD scans done till 1200 hrs are dispatched next day at 8:00 am while those done
after 12hours will be given after 1 day at 8:00 am
d. Mammography:
I. Is done only on Fridays. All OPD scans done till 1400 hrs are dispatched after 1 day
at 8:00 am
2. Turnaround time for emergency reports for all Procedures:
a. In case of an emergency X-Ray films are given within half an hour
8.7 Critical Results:

Communication Tools:
Manual: Including the manual processing, hand delivery or pick up to/by the testing area,
patient care area or physician / nurse / ward staff.
Verbal: verbal report in person or by telephone / intercom / mobile phone
Order of Notification:
• Ordering / Treating Physician / Staff nurse on duty / Medical Officer – Casualty/ICU

No 13
Critical Test Results Reporting and Documentation

Radiology
1. When the radiologist identifies a critical test result, a verbal report is given to the
ordering physician immediately in person or by phone.
2. If the ordering physician is not available, the radiologist immediately contacts their
assistant/concerned ward nurse and a verbal report is given in person.
3. If their assistant/concerned ward nurse could not be reached, the radiologist will
immediately follow the order of notification.
System Failures - Radiology

With any applicable communication system failure, the department incharge/radiographer will
give an in-person verbal report to the ordering physician
ACTIVITY AND RESPONSIBILITY
Critical Test Results Reporting and Documentation
S. no Procedural Responsibility
1. Radiology Technicians/ Ultrasonologist shall be vigilant about Radiographer on

the films which shows abnormality duty
/Ultrasonologist
2. In case any abnormal film is noticed, it has to be immediately Radiographer on

informed to the concerned doctor. In case doctor is not duty
available, order of notification given above is followed directly /Ultrasonologist
by technician
3. A verbal report is given to the ordering physician immediately in Radiographer on

person or by phone duty
/Ultrasonologist
4. If the ordering physician is not available, the radiographer Radiographer on

immediately contacts the other team member and a verbal report duty
is given in person / phone and then the staff nurse shall be /Ultrasonologist
responsible to inform the same to the concerned consultant.
5. If the staff nurse could not be reached, the radiographer will Radiographer on
duty

No 13
immediately follow the order of notification. /Ultrasonologist
6. Any delay in intimation of critical result is recorded in Radiographer on

compliance register with reason of the delay duty
/Ultrasonologist
8.8 Reporting of results:

All MRI and mammography results are reported in standardized manner. This includes name of
organization or outsourcing centre, name of patient, unique identification number and name and
signature of the person reporting the test result.
10.0 REFERENCES Scope of services: Policy no: (CHG/AAC/Doc no 01.00)

10.0 RECORDS AND FORMATS :Register

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Civil Hospital Gurgaon Standard Operating Procedure Document No CH/GGN /Rad/9

3.0 DEFINITION (IF ANY)

6.0 RESPONSIBILITYRadiology Department, Administration Department

7.0 DISTRIBUTIONRadiology Department, Administration Department, Safety Officer

Prepared By Issued By Approved By

8.0 PROCESS DETAIL

8.1 Legal & Other Requirements:

8.2 FACILITY AVAILABLE

8.5 Identification and safe transportation of patient to imaging services:

• All registered patients are given a unique identification no. OP/IP No

• For stretcher bound patient – accompanied by Class IV or staff nurse

• Reason for transportation is clearly explain to the patient /relative

Prepared By Issued By Approved By

8.6 Turn Around Time:

8.7 Critical Results:

• Ordering / Treating Physician / Staff nurse on duty / Medical Officer – Casualty/ICU

Prepared By Issued By Approved By

Critical Test Results Reporting and Documentation

System Failures - Radiology

1. Radiology Technicians/ Ultrasonologist shall be vigilant about Radiographer on

2. In case any abnormal film is noticed, it has to be immediately Radiographer on

3. A verbal report is given to the ordering physician immediately in Radiographer on

4. If the ordering physician is not available, the radiographer Radiographer on

Prepared By Issued By Approved By

immediately follow the order of notification. /Ultrasonologist

6. Any delay in intimation of critical result is recorded in Radiographer on

8.8 Reporting of results:

10.0 REFERENCES Scope of services: Policy no: (CHG/AAC/Doc no 01.00)

Prepared By Issued By Approved By

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