Diagnostic Testing and Screening Policy
Version
1
Name of responsible (ratifying) committee
Senior Clinical Management Team
Date ratified
15 February 2012
Document Manager (job title)
Diagnostic Imaging Manager / Consultant
Histopathologist
Date issued
8 March 2012
Review date
February 2013
Electronic location
Management Policies
Related Procedural Documents
Policy for the Management of Adverse Incidents and
Near Misses; Policy for the Management of SIRIs;
Radiological Policies and Procedures.
Key Words (to aid with searching)
In the case of hard copies of this policy the content can only be assured to be accurate on the date of issue marked on the
document.
For assurance that the most up to date policy is being used, staff should refer to the version held on the intranet
Diagnostic Testing Policy.
(Review date: February 2013
Issue 1
8 March 2012
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CONTENTS
QUICK REFERENCE GUIDE ...................................................................................................... 3
1.
INTRODUCTION.......................................................................................................................... 4
2.
PURPOSE ................................................................................................................................... 4
3.
SCOPE ........................................................................................................................................ 4
4.
DEFINITIONS .............................................................................................................................. 5
5.
DUTIES AND RESPONSIBILITIES ............................................................................................. 5
6.
PROCESS .................................................................................................................................. 7
7.
REFERENCES AND ASSOCIATED DOCUMENTATION ........................................................... 9
8.
EQUALITY IMPACT STATEMENT .............................................................................................. 9
9.
MONITORING COMPLIANCE ................................................................................................... 10
Appendix A: Reporting of Results ……………………………………………………………………….11
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QUICK REFERENCE GUIDE
For quick reference the guide below is a summary of actions required. This does not negate the need
those involved in the process to be aware of and follow the detail of this policy.
Diagnostic Test / Screening
Requested by Referring Healthcare Professional
Referrer makes note of test / examination request
in patient’s medical records
Booking and scheduling processes as required in
line with local processes
If rejected, requestor
notified
Diagnostic Test / screening performed (or
amended under IRMER for radiology requests)
and reported
Results produced and provided in accordance
with local policies and protocols
Unexpected findings
escalated in accordance with
local policies and protocols
Results viewed, acted upon accordingly and recorded by
requester
Note: all requesting clinicians, both medical and nonmedical, are responsible for reading and acting upon the
results of all tests that they request
Patients informed of all results by requestor or
nominated deputy, who should document that
discussion
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1. INTRODUCTION
The appropriate requesting and follow up of diagnostic and/or screening tests is an integral part
of patient treatment and also an area prone to error. Therefore it is important for patient safety,
quality and efficiency that these processes are managed well and that they perform reliably.
As a central part of clinical care, the correct management of diagnostic testing can help to
ensure that:

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


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Procedures are requested in line with patient clinical need, safety and consent
All requests are processed and can be tracked from request to conclusion
The results of tests lead to the correct diagnosis and patient care
Results are viewed, acted upon accordingly and recorded
The risk of misdiagnosis or failure/delay in diagnosis is minimized
Actions are taken to continuously improve patient outcomes and quality of care
2. PURPOSE
This policy covers the management of all diagnostic and screening tests/examinations from
request to reporting and results acknowledgement. Whilst general principles are outlined,
clinical areas must develop their own procedure specific documents in order to standardize
local working practices.
It will:


Ensure staff responsibilities and procedures for requesting all diagnostic and screening
tests / examinations are stated clearly in order to minimize the risk to patients and
improve patient outcome and quality of care
Outline expectations and provide Trust-wide guidance in relation to the development of
local detailed policies, protocols or standing operating procedures relating to the
requesting, reporting, results recording, and communication of the results of the tests /
examinations
3. SCOPE
This policy applies to all permanent, locum, agency, bank and voluntary staff of Portsmouth
Hospitals NHS Trust, the MDHU (Portsmouth) and Carillion, whilst acknowledging that for staff
other than those directly employed by the Trust the appropriate line management or chain of
command will be taken into account.
It includes the management of all diagnostic and screening tests/examinations including, but
not limited to:

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Radiological tests: Plain Film; Fluoroscopy; Ultrasound; CT; MRI; Nuclear Medicine
ECGs
Pathology tests/examinations from all disciplines, including: microbiology; haematology;
biochemistry; histopathology; cytology, molecular biology
Screening tests, including: bowel screening; breast screening
Note: it does not cover daily observational measurements such as heart rate, blood testing nor
self-testing by patients
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognises
that it may not be possible to adhere to all aspects of this document. In such circumstances,
staff should take advice from their manager and all possible action must be taken to
maintain ongoing patient and staff safety’
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4. DEFINITIONS
Acknowledger: any registered healthcare professional, either the original requester or
delegated person who become responsible for the patient’s continuing management
Diagnostic test: a diagnostic test is used to confirm whether or not there is the presence of
certain diseases or conditions. These tests often involve health risks and their use must
outweigh these risks. Examples include x-rays and cross-sectional imaging scans.
Justified (for radiological procedures/scans): formal IR(ME)R term for approval by a
recognised practitioner for any procedure involving the use of ionizing radiation to proceed on
the grounds that it is ‘clinically justified’ i.e. there is net benefit for the patient.
ICE: electronic system by which some pathology tests are requested and reported
NPSA Safer Practice Notice: a publication from the National Patient Safety Agency to which
all NHS trusts must respond and take action according to the published recommendations
Practitioner: IR(ME)R term for any appropriately qualified medical or dental or healthcare
professional who is entitled to take responsibility for approving an individual procedure involving
the use of ionizing radiation
Referrer: IR(ME)R term for any appropriately qualified medical or dental practitioner or
healthcare professional requesting an imaging procedure involving the use of ionizing radiation
(otherwise known as a ‘requester).
Reporter: any appropriately qualified medical or dental or healthcare professional who
interprets the diagnostic test results and produces a report for the healthcare professional to act
upon
Requester: any registered healthcare professional who requests a diagnostic test /
examination.
Royal College of Radiologists (RCR): the college responsible for the standards of
communication of critical, urgent and unexpected significant radiological findings
Screening: a process, often part of a programme, to identify the personal risk of developing a
disease or condition within well people e.g. bowel and breast screening
5. DUTIES AND RESPONSIBILITIES
Requester is responsible for:

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
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Adhering to all local policies / protocols
Obtaining patient consent, as appropriate to the proposed test
Ensuring requests for investigation / test is made appropriately by including:
o Patient demographic details i.e. surname, forename, date of birth, NHS number
o Details of requester, including contact information
o Date and time
o Clinical details
o Details of treatment or drug therapy
o Investigation required
o Indication of urgency
Failure to provide this information may lead to a delay or rejection of the request
Ensuring tests are only requested when the result will influence the diagnosis or
management of the patient and that the benefit of undertaking the test outweighs any
associated risks
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
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Receiving the results of the diagnostic test results. Results may be provided
electronically on the PACS and RIS systems or, for General Practitioners, on paper
Recording the results in the patient’s medical records – even if the results are normal
Taking (and recording) any action required following receipt of the test results
Ensuring the results of the test are communicated effectively
Note: all requesting clinicians, both medical and non-medical, are responsible for
reading and acting upon the results of all tests/examination that they request.
Reporter is responsible for:
 Ensuring local procedures / protocols are followed (Appendix A)
 Validating and authorizing the results in a timely fashion
 Where appropriate, providing advice on when tests should be repeated and/or
alternative imaging is justified.
Note: radiographs for inpatient and outpatient referrals will not be reported unless specifically
requested by the referrer.
Clinical Service Centre (CSC) Governance Leads are responsible for identifying all clinical
services that meet the definition of a ‘diagnostic or screening test’ and ensuring that:
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Appropriate policies / procedures / standard operating procedures are in place
A nominated individual is responsible for the implementation and review of any local
documents
The local document follows the requirements of this policy
The local documents are up to date and reviewed in line with their review date
Appropriate arrangements are in place for the audit/monitoring of local procedures and
that these are cross-referenced to the annual CSC / Specialty audit plans
Nominated Lead for Each Local Document are responsible for ensuring:
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Staff are aware of the local procedures and that there is evidence of cascade to staff
Implementation of the requirements of the local procedures, demonstrable by presence
in daily practice of each of the key staff groups affected
Ratification of agreed local procedures by a suitable committee / group as agreed with
the CSC Governance Lead
Reviewing and updating local procedures as and when clinical services or practices
change
Effectiveness of the local procedures is monitored in accordance with the requirements
set out in the documents themselves
Local procedures take into account any external bodies which have a role in the
effective management of systems to provide and manage diagnostic testing or
screening.
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6. PROCESS
6.1
Summary
Diagnostic Test / Screening
Requested by Referring Healthcare Professional
Referrer makes note of test / examination request
in patient’s medical records
Booking and scheduling processes as required in
line with local processes
Diagnostic Test / screening performed (or
amended under IRMER for radiology requests)
and reported
If rejected, requestor
notified
Imaging results
 Are posted onto PACS/RIS and are
available to internal referrer to view
 GPs are notified in hard copy
Screening results
 Are posted onto Apex and ICE
 GPs are notified electronically
Unexpected findings
escalated in accordance with
local policies and protocols
Results viewed, acted upon accordingly and recorded by
requester
Note: all requesting clinicians, both medical and nonmedical, are responsible for reading and acting upon the
results of all tests that they request
Patients informed of all results by requestor or
nominated deputy, who should document that
discussion
For full details of all pathology services, sample taking, testing and turnaround times, follow
pathology.
For full details of imaging services, follow diagnostic imaging
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6.2
Guidelines for the development of local policies, procedures and standard operating
procedures
The following must be incorporated as a minimum in local procedural documents relating to
diagnostic or screening tests
6.2.1
Process for requesting of tests

A standardized procedure for requesting to include:
o
o
o
o
o
o
6.2.2
Responsibilities and authorization of requesters and practitioners – including
arrangements for training, if required

Documented arrangements for:
o
o
o
o
6.2.3
The procedure for authorization (including any training) of requesters and
those undertaking test procedures
An outline of which specific skills/competencies are required to interpret
results of the test and how this will be overseen
Responsibilities of requesters to adhere to standard operating procedures or
equivalent protocols
Arrangements to ensure diagnostic/screening tests and procedures cannot
be requested and/or undertaken by unauthorized healthcare staff
Interpretation and communication of test results

Documented arrangements to include:
o
o
o
o
o
o
o
6.2.4
Who may and who may not request
The medium to be used (e.g. IT system/paper)
An outline of the key information required e.g. urgency, allergies,
investigation requested
Patient ID check procedure (including, where appropriate, labeling of scans
The process for ensuring that informed consent is obtained if required
Any alternate processes from the above standard procedure e.g. specific
emergency situation
Acceptable media for communicating tests results (e.g. IT system/paper)
All relevant acceptable methods / standards for communication of results
(e.g. key words, read-back procedures)
Processes in place to ensure the requester is aware of the
 Status of their request
 Results of their request
Acceptable timescales for the communication of results to the requester
Whether an interpretation of the result will be provided to the requester
Handover arrangements / requirements where the patient is transferred
between healthcare professionals / locations, including out of hours working
How the patient will be made aware of the test results; giving due
consideration to confidentiality, sensitivity and specific needs of the patient
Procedures for acting on results of tests


An outline and definition of any categories of result that determine the type or
timeliness of action required e.g. critical findings, normal result
The responsibilities of / subsequent actions required by the:
o
Requester
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o

6.2.5
The target timescales within which actions should be taken
Documentation / audit trail to be monitored


All documentation/audit trail instructions must be in line with Trust records
management policy
Documented arrangements for the recording of diagnostic/screening test results
should include robust processes for ensuring that the following are recorded in the
designated media
o
o
o
o
o
6.2.6
Professional or department providing the result, report or result interpretation
Time, date and individual informed of the result receipt
Whether the result should be filed in the patient’s medical records and, of so,
how this information will be transferred from the medical device
Management plan / identified actions
Whether the patient informed
The method of communication used e.g. face to face, telephone call, letter
Monitoring effectiveness

Each local procedure should outline plans to monitor compliance and address any
required issues. As a minimum this should include:
o
o
o
o
o
Who will perform the monitoring
The frequency of monitoring
Auditable standards and/or key performance indicators
The group to whom the audit will be reported
Responsibilities for addressing any shortfalls
7. REFERENCES AND ASSOCIATED DOCUMENTATION
External
 National Patient Safety Agency, Safer Practice Notice 16 2007 – Early Identification of
Failure to Act on Radiological Imaging Reports
 Royal College of Radiologists – Standards for Communication of Critical, Urgent and
Unexpected Significant Radiological Findings (June 2008)
 Royal College of Radiologists – Standards for a Results Acknowledgement System
(February 2010)
 IRMER 2000 and IRMER regulations
 National Patient Safety Agency (2004) Right Patient, Right Care
 The Ionising Radiation Regulations
Internal
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Policy for the Management of Serious Incidents Requiring Investigation
Policy for the Management of Adverse Incidents and Near Misses
Pathology
diagnostic imaging
8. EQUALITY IMPACT STATEMENT
Portsmouth Hospitals NHS Trust is committed to ensuring that, as far as is reasonably
practicable, the way we provide services to the public and the way we treat our staff reflects
their individual needs and does not discriminate against individuals or groups on any grounds.
This policy has been assessed accordingly
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9. MONITORING COMPLIANCE
As a minimum the following elements will be monitored to ensure compliance
Minimum requirement to
be monitored
Lead
Tool
Frequency of
Reporting of
Compliance
Action to be taken following
the diagnostic test results,
including time scales: 100%
of appropriate action and
time scales
Clinical Director
/Audit Lead
Random audit of 50
inpatient and outpatient
records
Annually
Consultant
Histopathologist/
Audit Lead
Random audit of 50
inpatient and outpatient
records
Annually
Reporting arrangements
Lead(s) for acting on
recommendations
Policy audit report to:

Clinical Director Diagnostic
Imaging / CSC Heads of
Governance
Radiology audit meeting
Process for recording who is
informed of the diagnostic
test results: appropriate
recording in 100% of cases
Actions to be taken following
the screening results: 100%
of appropriate action and
timescales

Process for recording who is
informed of the screening
results: appropriate in 100%
of cases
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(Review date: February 2013
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Policy audit report to:
Page 10 of 11
Pathology Department
meeting
audit
Clinical Directors Pathology
Department / CSC Heads of
Governance
Appendix A
Reporting of Results
1. REQUESTS SUBMITTED MAIN RADIOLOGY DEPARTMENT
1.1. Timescales
Timescales for reporting and issuing of results are published on the radiology dashboard
1.2
2.

Inpatients within 24 hours

Outpatients within 48 hours

GP referrals within 7 days

Emergency Department within 1 working day
Delivery of results

Results are posted onto PACS or RIS: available for referrer to view

General Practitioners are notified in hard copy

Clinically serious or extreme results e.g. cancers/trauma, will be alerted to the
referrer by telephone
REQUESTS SUBMITTED TO PATHOLOGY
2.1
2.2
Timescales
Timescales for turnaround of test results are timed from when samples are received in the
laboratory

Emergency Department within 1 hour

Urgent within 2 hours

Routine one day

Complex and/or specific tests will be reported in accordance with Pathology
Handbook INSERT LINK
Delivery of results

Results are posted onto Apex and ICE: available for internal referrer to view

General Practitioners are notified electronically

Clinically serious or extreme results e.g. cancers/trauma, will be alerted to the
referrer by telephone
For details of pathology turnaround times, follow pathology.
For details of imaging services, follow diagnostic imaging
Diagnostic Testing Policy.
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