CLINICAL SERVICE PRACTICE
POLICY STATEMENT
Referring for Medical Imaging
Purpose:
The purpose of this Policy is to
direct the correct use of irradiating apparatus and other medical imaging equipment modalities
provide clarification of the correct avenues for referring patients for medical imaging
give a clear reference for Radiology staff on accepting referrals
Scope:
This policy covers all Radiology requests by primary, secondary and Health Professionals.
Definitions:
MIT: Medical Imaging Technologist (Radiographer)
ED:
Emergency Department
OAO: Outpatient Appointment Office
NP:
Nurse Practitioner
CTC: CT Colonography
RIS:
Radiology Information System – Comrad
CSPM Clinical Services Practice Manual
IVU
Intravenous Urogram
Interventional At Risk Appointments – a procedure that requires an on-site surgeon to be available
e.g. Liver Biopsy.
Policy Statement:
The following may request a Radiological investigation:
Registered Medical Practitioners - All radiological examinations
ED Nurses – “ED Nurse Initiated X-ray Ottawa Ankle Rules” as per ED Protocol E5, or Nurse
Initiated Xray in Emergency Department E7.
Nurse Practitioner – same referring rights as General Practitioners after completingHealthlearn
Course CAMS009 Radiology Imaging Referral
Chiropractor
Physiotherapist Plain x-rays only, within referrer's specialised field
Podiatrist
Nurse with Post Grad Study who have completed CAMS009 Radiology Imaging Referral on
Healthlearn
Specialist Nurses working in Orthopaedic, Oncology, Cardiology or Urology Clinic who have
completed CAMS009 Radiology Imaging Referral on Healthlearn These referrals are for the
following imaging only as laid down by the speciality consultant:
o
Orthopaedic clinic in nurse-led clinic may request imaging of follow-up knee and hip
surgery, or other examinations after consultation with the named Orthopaedic Surgeon
(stated on the referral). This includes DEXA bone scans.
o
Cardiology Nurse Specialist may request chest x-rays.
o
Oncology Nurse Specialist may request chest x-rays and follow up CT scans after
consultation with named Oncologist (stated on referral)
o
Urology Nurse Specialist may request relevant imaging after discussion with the named
consultant, or in accordance with the Urology Nurse Referral Triage Guidelines
OPDUR003 located in Service Framework.
AUTHOR:
Clinical Leader Radiology
FILE NUMBER:
CSPM R15
AUTHORISED:
Jan 2021
REVIEW DUE:
Jan 2023
This is a controlled document. The electronic version is the most up-to-date. Printed versions are valid on the day of printing only.
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CLINICAL SERVICE PRACTICE
POLICY STATEMENT
Radiology staff are responsible for ensuring no request is accepted, other than those deemed to be
from referrers listed above. Lists of Nurses with referring rights can be found in the Radiology
Safety Register.
Procedure:
Prior to the request of imaging, a complete history and assessment of the patient must be
undertaken and documented:
Patient’s physical condition and past medical history must be considered.
Consider any previous imaging
Establish if there is any chance of pregnancy
Provide sufficient information on the clinical context of the procedure in the referral for the
Radiologist to answer the clinical question.
Interventional At Risk Appointments from Private Referrers:
Ensure the patient is under a SCDHB consultant. If not, pass referral to Radiology Manager who will
send a letter to referrer explaining the correct process i.e. they must refer through OAO for a
SCDHB consultant. This advisory letter is then scanned into the patient documents in Comrad RIS.
No forms can be changed at the request of a patient to include or exclude any area of examination,
or be performed at other times than those requested by the referrer, without the referrer being first
consulted. Should such a change be agreed to by the referrer, the details and date of the change
should be noted on the referral concerned and the document scanned into the patient details of the
Comrad RIS against the applicable examination reference. The exclusion to this is when it is clear
the incorrect side has been requested. In this case the error should be documented by the MIT.
Alert:
SCDHB Radiology Hours of Work:
At least one MIT is on site 24 hours.
Reception is manned 0700-1700 Monday to Friday.
MIT can be contacted by pager through switchboard.
CTs may only be requested after discussion with the consultant involved, unless referred by a Senior
Medical Officer. Exception being CT Head/CT – C Spine as per SCDHB RMO Investigation
Guidelines R33, midnight to 7am.
If contrast is required the patient should have the appropriate cannula in situ and have a recent blood
test to assess kidney function.
Reporting of After Hours Work: CTs:Report available on CIS within 1-2 hours. Life or limb threatening will be phoned to referrer.
X-rays :
Report should be available within 4 hours. Life or limb threatening will be phoned to
referrer.
Process:
All incoming referral forms must be checked by a Radiology clinical staff member so any
unacceptable requests can be returned with a letter of explanation. Any such letter must be
scanned into the Comrad RIS with discussion with Radiology Manager or Clinical Leader if
necessary.,
The referral process is clarified by modality as follows:
AUTHOR:
Clinical Leader Radiology
FILE NUMBER:
CSPM R15
AUTHORISED:
Jan 2021
REVIEW DUE:
Jan 2023
This is a controlled document. The electronic version is the most up-to-date. Printed versions are valid on the day of printing only.
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CLINICAL SERVICE PRACTICE
POLICY STATEMENT
1.
Plain X-rays
Emergency Department Referrals:
Form completed by ED doctor (or ED Nurses as per ED protocol, “ED Nurse Initiated X-ray Ottawa
Ankle Rules” E5) and given to MRT in ED. (If MRT is not in ED they can be paged or by using
normal channels of contact in an On Call situation).
Outpatient Clinic Referrals:
Form completed by Outpatients' doctor, except for the Nurse Led Orthopaedic Clinic in which case the
specific Orthopaedic Nurse, requests the appropriate x-ray.
Ward Referrals:
Form completed by doctor. Can be faxed to department or left at reception. Patient’s transport
arranged by MITs.
AFTER HOURS: Referring doctor contacts "On Call" MRT by pager.
GP/Private Referrals/Nurse Practitioner (NP):
Form completed by doctor/specialist/NP:
Form is received via ERMs or fax and reception staff book appointment for all imaging.
2.
Other Modalities (e.g. CT, Ultrasound, Fluoroscopy)
NB: Urgent to be done that day including must always be approved and prioritised by appropriate
Radiology clinical staff this can be co-ordinated through Radiology reception.
Emergency Department Referrals:
Form completed by ED doctor and Faxed to Radiology. CTs can be faxed directly to Radiology CT
fax 8697 and page MIT.
Outpatients Referrals:
Patient to be informed by doctor of intention to book a procedure. Form completed by doctor and
delivered/faxed/mailed or via ERMs to Radiology for entry into waiting list.
Ward Referrals:
Form completed by doctor, delivered to Radiology for appointment and preparation advice.
GP/Private/Nurse Practitioner Referrals:
ERMS Form mailed/faxed to Radiology and entry into waiting list is made. Appropriate preparation
arranged and subsequent booking made.
N.B: As per the Radiology Appointment Booking Manual.
CTs not referred by a SCDHB consultant through ED, Ward or Outpatient Clinic visit are not publicly
funded and therefore are payable by the patient, ACC or medical insurance if applicable. Medical
Imaging referrals performed offsite for SCDHB e.g. DEXA scans, are publicly funded if referred
through a SCDHB consultant.
Some plain x-rays are not publicly funded e.g. private dental imaging and chiropractor referrals.
Immigration Chest x-rays are not performed at all.
3.
MRIs, DEXA Scans, Vein Mapping:
MRI, All referrals must come through Medical Specialist:
ACC MRIs:
Referrals for these are sent directly to the department preferred, by referring consultant.
AUTHOR:
Clinical Leader Radiology
FILE NUMBER:
CSPM R15
AUTHORISED:
Jan 2021
REVIEW DUE:
Jan 2023
This is a controlled document. The electronic version is the most up-to-date. Printed versions are valid on the day of printing only.
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CLINICAL SERVICE PRACTICE
POLICY STATEMENT
Outpatient:
Mail/deliver request to Radiology where they are assessed for appropriateness. An ACC check may
be done. Patient is contacted with appointment time.
Inpatient:
Request discussed by referring doctor and MRI staff to ascertain urgency. Ward advised of
appointment time.
All safety and consent forms must be completed at the time the request is submitted.
Dexa Scans and Vein Mapping: Requests are made on Timaru Hospital radiology request forms and delivered/mailed to the
Radiology Office.
3.
Nuclear Medicine
Arranged by referring SCDHB consultant - Radiology not involved except in payment.
Associated Documents:
J:\\ Service Framework\02-Emergency Department/Protocols
Nurse Initiated X-ray in ED E7
&procedures.
ED Nurse Initiated X-ray Ottawa
J:\\Service Framework\Emergency Department\Protocols &
Ankle Rules E5
Procedures
Radiology Receptionist Manual
J:\\Radiology/Quality/Admin
Radiology - On Call Protocol
CSPM R29 – iHub/Polices/Clinical Services Practice Manual
Radiology Booking Administrator
J:\\Radiology/Quality/Admin
Desk File ADM002
Radiology Appointment makeup
J-Drive: Radiology/Quality/Admin
ADM008
RMO Guidelines CSPM R33
– Ihub/Policies/Clinical Services Practice Manual
Code of Practice for Diagnostic and ORS C1 Ministry of Health website.
Interventional Radiology.
AUTHOR:
Clinical Leader Radiology
FILE NUMBER:
CSPM R15
AUTHORISED:
Jan 2021
REVIEW DUE:
Jan 2023
This is a controlled document. The electronic version is the most up-to-date. Printed versions are valid on the day of printing only.
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