Name the service Service
Name the service Nurse/Nurse Practioner Initiated Radiology Referral
Agreement
Name the department Agreement for (Adult) Nurse/Nurse Practitioner Initiated
Radiology Referral
Process
Who
• Approval from department Nursing lead (Nursing
Director, Nurse Manager) and Clinical Director to
proceed.
• Draft / complete the agreement based on
template
Nursing Lead
(CNS, CNM)
• Send the agreement to the Clinical Director/Chief
of Service for approval / signature (as email
attachment)
Nursing Lead
(CNS, CNM)
• Sign electronically / insert signature and send to
Director of Nursing (DON) by email
Clinical Director/
Chief of Service
• Director of Nursing to send onto the Chief of
Radiology for signing (by email).
PA to DON.
•
Chief of Radiology
Chief of Radiology signs and holds original
Name
Tick
Nursing Lead
(CNS, CNM)
 Copy emailed to Director of Nursing for filing
(or in hard copy)
•
DON’s office sends copy to Service (advising of
outcome.
PA to DON.
Please keep this page attached to the document to track the progress of the
signing
Please contact Janette Dallas if you have any questions
Name the service Service
Name the service Nurse/Nurse Practioner Initiated Radiology Referral
Agreement
Name the department Agreement for (Adult) Nurse/Nurse Practitioner Initiated
Radiology Referral
Agreement
This agreement allows nurses within name the service at
Christchurch Hospital and who are registered with the Nursing
Council New Zealand and who have completed the required training
to initiate electronic or hard copy referrals to radiology for diagnostic
or interventional radiological procedures to facilitate appropriate and
timely management of name the service adult patients.
Scope/Audience

name the service Clinical Nurse Specalists
 name the service Senior Medical Officers and Registered
Medical Officers.

name the service Charge Nurse Managers

Chief of Radiology

Radiologists, MRTs and Radiology nursing staff
Associated Documents








Nursing Council New Zealand scopes of practice for Registered
Nurse and Nurse Practitioner.
CDHB Manual, Volume D – Nursing Policy and Procedures,
Midwife, Nurse Practitioner and Nurse Initiated Radiology
Referrals Policy.
CDHB Radiation Safety Plan.
Diagnostic Radiology Consultation Form (QF00294).
Interventional Radiology Consultation Form (QF01157).
CDHB healthLearn Nurse Midwife Radiology Referrals
programme.
Radiation Protection Act.
Name any additional documents
Roles and responsibilities
Clinical Nurse Specalists ordering radiological procedures must
ensure

They are practising within their professional scope.
The latest version of this document is available on the CDHB intranet/website only.
Printed copies may not reflect the most recent updates.

Authorised by:
Page 2 of 5
Issue Date:
Be reviewed by:
Name the service Service
Name the service Nurse/Nurse Practioner Initiated Radiology Referral
Agreement

They have completed the requirements for nurse initiated
radiology referrals as set out in the Midwife, Nurse Practitioner
and Nurse Initiated Radiology Referrals Policy.

The SMO or team responsible for reviewing the report and acting
on any abnormality is clearly identified as name the service.

The Clinical Nurse Specalist requesting the radiology referral will
notify the appropriate name the service / team and inform them
of the request and the reason for doing so.
The Name the service agrees that

Follow-up on any nurse initiated radiology result will be the
responsibility of the name the service team nominated on the
radiology referral.

An annual audit will be carried out under the direction of the
name the service Clinical Director to monitor the quality of
clinical information, appropriateness of the request and the
requested timing/priority of the investigation. This will be
reported annually and forwarded to the name the service Clinical
Director for review.

The nursing lead for the service will maintain the list of nurses
who have completed the training and gained the competency.
This will be forwarded to the Professional Development Unit to
be recorded on the training competency data base.
Agreement Statement

Outline of why this is needed an example is as below.
There are a number of CNS positions within the respiratory service, and this
group of nurses provide care for a range of patients with both acute and
respiratory disease. The CNSs may see patients in nurse-led clinics, ward
based reviews or during home visits. Referrals for radiological imaging, PICC
insertions and Portacath contrast studies may be requested by a respiratory
CNS to facilitate the timely care and management of respiratory patients in the
following circumstances:
Inclusions/ clinical indications ( example as below)
Chest X-rays

Respiratory patients attending an outpatient or ward review by a CNS who
have an acute onset of respiratory symptoms such as increased breathless or
The latest version of this document is available on the CDHB intranet/website only.
Printed copies may not reflect the most recent updates.

Authorised by:
Page 3 of 5
Issue Date:
Be reviewed by:
Name the service Service
Name the service Nurse/Nurse Practioner Initiated Radiology Referral
Agreement
chest pain. A respiratory assessment of the patient including examination and
auscultation of the chest will be carried out by the CNS prior to requesting a
chest x-ray.
Abdominal X-rays

Referral for an abdominal x-ray may be requested for Cystic Fibrosis (CF)
patients who attend the hospital for review by the CF CNS. This includes
those with a history of abdominal pain, bloating, reduced appetite,
nausea/vomiting or a previous history of distal intestinal obstruction syndrome.
A physical assessment of the patient will be carried out by the CF CNS prior
to requesting an abdominal x-ray.
PICC Line Requests

Referrals for PICC line insertions may be requested for respiratory patients
requiring antibiotic therapy who will be completing some or all of their
treatment at home.
Portacath Dye Study

A portacath/CVAD contrast study may be requested as set out in the “Flow
Chart to Restore Catheter Patency” document in the CVAD resource book.
This would only be requested after attempts to restore patency using alteplase
have failed.
Measurement/Evaluation

An audit of nurse initiated radiology referrals will be conducted
annually by a person nominated by the Clinical Director of
Name the service.

Ten referrals for each nurse authorised to request radiology
services will be audited annually for the quality of the clinical
information on the referral, appriopriateness and requested
priority/timing.

A summary of the audit will be made available to the Clinical
Director of Name the service , the Chief of Radiology and the
Director of Nursing.
__________________________________________________________________
The latest version of this document is available on the CDHB intranet/website only.
Printed copies may not reflect the most recent updates.

Authorised by:
Page 4 of 5
Issue Date:
Be reviewed by:
Name the service Service
Name the service Nurse/Nurse Practioner Initiated Radiology Referral
Agreement
Referral Agreement Approval
Clinical Director/Chief of Service _____________________________________
Signature _______________________________________________
Date
/
/
Approved by Chief of Radiology______________________________________
Signature _______________________________________________
Date
/
/
Approved by Director of Nursing_____________________________________
Signature _______________________________________________
Date
/
Radiology Administration:
Add approved policies to on-line register
Copy approval to Director of Nursing
Agreement Owner
Clinical Director Name the service
Director of Nursing
Authoriser
Chief of Radiology (Principal Licence Holder)
Date of Authorisation
dd month 20xx
The latest version of this document is available on the CDHB intranet/website only.
Printed copies may not reflect the most recent updates.

Authorised by:
Page 5 of 5
Issue Date:
Be reviewed by:
/