RADIOLOGY
Quality Manual
Radiology Referral Quality
Policy Responsibilities and Authorisation
Department Responsible for Policy
Radiology
Document Facilitator Name
Sally McMillan
Document Facilitator Title
Quality Manager
Document Owner Name
Dr Glenn Coltman
Document Owner Title
Radiology Clinical Unit Leader
Disclaimer: This document has been developed by the Radiology department, Waikato District Health
Board specifically for its own use. Use of this document and any reliance on the information contained
therein by any third party is at their own risk and Waikato District Health Board assumes no responsibility
whatsoever.
Doc ID: RAD-2011.03 Version: 3
Issue Date: 22 July 2020
Review Date: 04 February 2022
Authorised By
Sally McMillan
IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING.
Page 1 of 4
RADIOLOGY
Quality Manual
Radiology Referral Quality
1. Introduction
1.1 Purpose
To give guidance to Resident Medical Officers (RMOs) on the acceptable standard of
referrals for imaging to the Radiology department, that the referrals are of a quality
standard, and ensure patient safety and referral pathways are met.
1.2 Scope
All Resident Medical Officers (RMO) and Senior Medical Officers (SMO)
1.3 Exclusions
Nurse Practitioners are required to adhere to the Waikato DHB X-ray Referral Process for
Nurse Practitioners guideline (5975)
2. Definitions
GP
General Practitioner
MOH
Ministry of Health
ORS
Office of Radiation Safety
RMO
Resident Medical Officer
SMO
Senior Medical Officer
3. Policy Statements / Key Points
These guidelines have been developed to ensure patients that are referred to the
Radiology department receive the most appropriate form of imaging within an acceptable
time frame.
The referrer has prime responsibility for, and must be competent to provide sufficient and
necessary clinical information for the Radiology service.
The information that is required for an acceptable referral must be clarify the patient’s
details, clinical history, clinical question to be answered, and the most appropriate
examination.
Education of referrers as to what constitutes an acceptable imaging referral is essential in
reaching and maintaining the quality of referrals to the Radiology service.
A process of a routine Radiology Referral education sessions at key opportunities is
embedded into the organisation.
External factors that must be considered include the MOH ORS Code of Practice, and the
Radiation Safety Act (2016).
4. Roles and Responsibilities
RMO:
Responsible clinician who signs the referral, and whom has the overall responsibility for
the Radiology referral including the acknowledgement of results
Shall record clearly and legibly
Should seek advice from the on-call Radiology Registrar if in doubt around any aspect
of the referral, including urgency
Doc ID: RAD-2011.03 Version: 3
Issue Date: 22 July 2020
Review Date: 04 February 2022
Authorised By
Sally McMillan
IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING.
Page 2 of 4
RADIOLOGY
Quality Manual
Radiology Referral Quality
Clinical Unit Team Leader:
Responsible for ensuring this policy is complied with in the Radiology Service
Communicating the results of audits with the referring RMO.
Radiology District Service Manager:
Support the Clinical Unit Leader ensuring compliance to this policy
Quality Manager:
Establish and maintain a process of education for referrers
Establish and maintain an audit tool for the quality of Radiology referrals
Audit the quality of the referral forms annually
Radiology Consultant and Radiology Registrar:
Be available to offer general advice to referrers
Radiology Educator:
Present the established Radiology Referral Education session when required
5. Referral Criteria
All Imaging referrals shall have included:
Correct Patient Identification (NHI, full name, DOB, Address)
Responsible Unit (Waikato DHB referrals)
Signature, with legible name
Date of referral
Sufficient clinical history to justify the imaging referral
A clinical question to be answered by imaging
Examination / Correct body part for imaging
All other patient information that contributes to the management of the patient
patient alerts regarding patient / client adverse drug reactions and allergies or other risk
alerts
Urgency
Communications with the Radiology department must be recorded on the referral
Clear and legible writing
6. Education
6.1 Requirements
Education requirements include:
Nature of Ionising Radiation
Principles of Radiation Safety (including justification)
Legislative requirements
The Radiology service
Referrals for Imaging
Referral form completion
Delegation and Responsibility
Acknowledgement of results
Consequences
Doc ID: RAD-2011.03 Version: 3
Issue Date: 22 July 2020
Review Date: 04 February 2022
Authorised By
Sally McMillan
IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING.
Page 3 of 4
RADIOLOGY
Quality Manual
Radiology Referral Quality
6.2 Meetings
RMO Orientation
Quarterly speciality meetings
GP Education session
7. Audit
7.1 Indicators
100% of Radiology referrals completed will be accurate and acceptable to the service.
100% of Radiology referrals will have the correct patient information and correct side
recorded.
7.2 Tools
An audit of all imaging referrals is to be undertaken for a period of 2 weeks, twice yearly.
Radiology Unit Charges will be responsible for collecting incorrect referral forms for
analysis, with follow-up notification to the responsible referrer.
A published ‘zero-tolerance to incorrect Radiology referrals’ week, which see’s all
incorrect referral forms returned to the referrer upon receipt, will be held 6 monthly.
All incorrect side requests and incorrect patient identification will be documented via Datix.
8. Legislative Requirements
8.1 Legislation
Radiation Safety Act (2016)
8.2 External Standards
Ministry of Health Office of Radiation Safety Code of Practice C1, C3
9. Associated Documents
Waikato DHB: Specialty Referral Guidelines (Ref. 5295)
Waikato DHB: Clinical Records Management (Ref. 0182)
Waikato DHB: Trauma Protocol (Ref. 1538)
National Criteria for Access to Community Radiology 2015
Doc ID: RAD-2011.03 Version: 3
Issue Date: 22 July 2020
Review Date: 04 February 2022
Authorised By
Sally McMillan
IF THIS DOCUMENT IS PRINTED, IT IS VALID ONLY FOR THE DAY OF PRINTING.
Page 4 of 4
Document Outline
