X-Ray Images Written Evaluation Policy
Version
4
Name of responsible (ratifying) committee
Radiology IRMER Group through Medical Radiation
Committee to Trust Clinical Governance
Date ratified
12 February 2015
Document Manager (job title)
Louis Merton – Clinical Director Diagnostic Imaging
Martin Firth – Consultant Radiologist and IRMER lead
Janine Hatch – Imaging Services Manager
Catrin Ferioli – Trust Radiation Protection Adviser
Date issued
13 February 2015
Review date
12 February 2016
Electronic location
Clinical Policies
Related Procedural Documents
See section 8 of this policy
Key Words (to aid with searching)
IRMER Written Evaluation Evaluation; Reporting
procedures; Radiologists; Medical staff; Reports.
Version Tracking
Version
Date Ratified
Brief Summary of Changes
Author
4
12/02/2015
Change of document manager names, change of
document format
IRMER GROUP
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
Page 1 of 13
CONTENTS
QUICK REFERENCE GUIDE ...................................................................................................... 3
1. INTRODUCTION ......................................................................................................................... 4
2. PURPOSE ................................................................................................................................... 4
3. SCOPE ........................................................................................................................................ 4
4. DEFINITIONS .............................................................................................................................. 4
5. DUTIES AND RESPONSIBILITIES .............................................................................................. 5
6. PROCESS ................................................................................................................................... 6
7. TRAINING REQUIREMENTS ...................................................................................................... 6
8. REFERENCES AND ASSOCIATED DOCUMENTATION ............................................................ 7
9. EQUALITY IMPACT STATEMENT .............................................................................................. 7
10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS .......................................... 8
APPENDICES:
Appendix 1:
PHT Radiology department, other departments and procedures supported with X-ray equipment…..9
Appendix 2:
PHT Radiology reporting schedule and specialty arrangements……………………………………… 10
Appendix 3:
Specialties with arrangements for medical staff to undertake the role of IRMER Practitioner………11
Appendix 4:
Exceptions……………………………………………………………………………………………………12
Appendix 5:
Access to Radiologists……………………………………………………………………………………..13
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
Page 2 of 13
QUICK REFERENCE GUIDE
This policy must be followed in full when developing or reviewing and amending Trust procedural
documents.
For quick reference the guide below is a summary of actions required. This does not negate the need
for the document author and others involved in the process to be aware of and follow the detail of this
policy. The quick reference can take the form of a list or a flow chart, if the latter would more easily
explain the key issues within the body of the document
1. This document details means by which statutory responsibilities for making a written record of
the evaluation of radiological examinations/procedures are met.
2. The primary duty to ensure that the written record of the evaluation of a radiological
examination/procedure is made rests with the referring specialty – referrer (Appendix 2)
3. Written evaluations may be undertaken by others on behalf of the Referrer where
documented agreements are in place, e.g. with Radiology for radiologists reports.
4. Referrers are able to seek specialist opinions, assistance or support from Radiologists in the
Radiology Access Unit (RAU) (Appendix 5).
5. Referrals for radiological procedures constitute one part of the patient’s management. It is the
responsibility of the referrer to ensure that the request is documented to ensure the use of
resultant information to inform decisions concerning further management of the patient.
6. Elements of the process may be delegated to a suitably trained and qualified professional but
the ultimate responsibility for the quality of medical care rests with the Consultant
(Practitioner) responsible for the patients care.
7. Application and effectiveness of this policy is monitored through Audit and overseen through
Audit reports and exceptions by the Quality and Governance Committee
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
Page 3 of 13
1. INTRODUCTION
All X-ray images taken as part of diagnosis, treatment, ongoing medical management and
research must have a traceable record of the image being evaluated by a recognised medical
practitioner or allied health professional delegated with this responsibility. This is a legal duty
under the Ionising Radiation (Medical Exposures) Regulations 2000 (IRMER)1. Any exposure
to X-rays is unjustifiable if it is known in advance that the images will not be evaluated.
http://www.opsi.gov.uk/si/si2000/20001059.htm
2. PURPOSE
This policy will ensure the implementation of the statutory requirement for written evidence of
clinical evaluation of medical X-rays in all clinical areas, contributing to appropriately
documented medical records.
3. SCOPE
The policy applies to the evaluation of all X-ray images of patients referred to and examined
in Portsmouth Hospitals Radiology departments, by PHT Radiology staff or by others using
X-ray equipment on Portsmouth Hospitals NHS Trust premises, extending also to other
departments and services where X-ray imaging is employed in diagnosis and treatment, e.g.
Cardiology, Pain Clinic, Radiotherapy, Nuclear Medicine. These are listed in detail in
Appendix 1.
‘In the event of an infection outbreak, flu pandemic or major incident, the Trust recognizes
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’
4. DEFINITIONS
Evaluation:
A documented evaluation is a record that evidences the examination of an X-ray image, or
analysis of X-ray data, leading to a decision concerning the clinical status of the subject
related to the initial purpose for which the X-ray exposure was undertaken.
From IRMER: "evaluation" means interpretation of the outcome and implications of,
and of the information resulting from, a medical exposure;
Referrers:
All Portsmouth Hospitals and MoD MDHU medical and dental staff are eligible to refer
patients for x-ray examinations. Individual allied health professionals can be authorized as
referrers for specified examinations by arrangement with the Radiology department. Medical
staff using image intensifier equipment are considered to be referrers, unless covered by
specified arrangements detailed in Appendix 3
Referrals should conform to the Portsmouth Hospitals Radiology Referral Guidelines
(available via the intranet) or be by prior discussion with a Radiologist.
Internal departmental procedures will apply where X-rays are part of other investigations or
treatments in Nuclear Medicine and Radiotherapy.
From IRMER: "referrer" means a “registered healthcare professional” who is entitled
in accordance with the employer's procedures to refer individuals for medical exposure
X-ray Images – Written Evaluation Policy
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Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
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to a practitioner; "registered health care professional" means a person who is a
member of a profession regulated by a body mentioned in section 25(3) of the National
Health Service Reform and Health Care Professions Act 2002."
Record:
The record may be a Radiologists report, clinicians record in the patients notes which indicates
use of the radiological information in diagnosis or treatment, marking up of films or images,
treatment decisions or outcomes (e.g. “wires correctly located”) related to the procedure,
printed data from analysis of X-ray data (e.g. DEXA scan results). A list of procedures that
constitute exceptions is given in Appendix 4
5. DUTIES AND RESPONSIBILITIES
Referring specialties are responsible for recording the evaluation of all radiographs, whether
returned as films or on PACS. This may be by a delegated allied health professional within the
specialty. The responsibility extends to evaluation of features relevant to the clinical question /
reason for referral, against which the examination has been carried out.. Exceptions to this are
where a report is provided by a radiologist, or as specified in Appendix 2 - PHT Radiology
reporting schedule and specialty arrangements.
Supporting opinion:
Referrers may at any time seek assistance or support from more experienced colleagues within
their own specialty, on request from a radiologist in the RAU (Appendix 5 – Access to
Radiologists), or by making a specific request to a Radiologist. This may include seeking an
opinion concerning a suspicion of abnormal pathology that is beyond the reason for the original
referral.
Ongoing clinical care of the patient:
It is the referrers / referring medical practitioner’s responsibility to make it clear in the notes that
a referral for a radiological investigation has been requested. Where images are subsequently
provided by radiology, these must be evaluated and a record made in the notes / on PACS by
the medical practitioner dealing with the patient at the time, and in consultation with colleagues
within the medical team where additional expertise is required.
Liability:
Medical staff (not trained as radiologists) shall only be responsible for the validity of the
evaluation as it relates to the reason for referral and within the scope of their own
expertise. Suspicious pathology should however be identified wherever possible and a
supporting opinion sought in such cases.
Elements of the process may be delegated to a suitably trained and qualified
professional but the ultimate responsibility for the quality of medical care rests with the
Consultant responsible for the patients care.
The referring clinician should liaise with colleagues to discuss interpretation of routine referrals
and seek opinions from experienced and senior colleagues in cases where their experience is
limited. Use should be made of the RAU (Appendix 5 – Access to Radiologists) to discuss
individual cases, areas of suspicious pathology etc. Requests for radiologist’s reports should be
the exception where there is no reporting agreement in place.
The Patient Safety Steering Group, with support from the Medical Radiation Committee, will
oversee the application of this policy in conjunction with agreements and referral practices as
monitored by Radiology.
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
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6. PROCESS
ACTION
All investigations or
treatments using Xrays must have
documented
evaluation in the
patient’s notes.
RATIONALE
EVIDENCE
Adoption of best practice
in clinical management of
patients.
1
Reference
Compliance with statutory
obligations under IRMER.
ASPECT OF CARE / OUTCOMES
EXPECTED
STANDARD / TARGET
Potential
Risks/Harms
Unnecessary use of
radiological
investigations and
exposure to X-rays.
Inadequate clinical
care
Risk of enforcement
action /prosecution
for non-compliance
with statutory
responsibilities
SOURCE OF DATA
COLLECTION
Periodic audit
Written evaluation of X-ray procedure in the
patient’s notes
100% of investigations /
treatments
Radiologists report where required within
existing agreements
100% of investigations /
treatments
External inspection
by the CQC IRMER
team
Periodic audit
External inspection
by the CQC IRMER
team
7. TRAINING REQUIREMENTS
Medical staff will have received basic training in the interpretation of X-ray images during the
undergraduate and foundation years. Further training relevant to their specialty is acquired
during the SPR appointment.
Competency will be achieved through completion of the CCST (Certificate of Completion of
Specialist Training). This is under the jurisdiction of the Specialty Training Schemes.
Non-medical staff undertaking evaluation of images are trained through individual training plans
under the supervision of a Reporting Radiographer and a nominated Radiologist.
Allied Health Professionals undertaking X-ray procedures within departments of Nuclear
Medicine and Radiotherapy will adhere to local procedures approved by their lead Practitioner.
Specialty Consultants undertaking the role as IRMER Practitioner must have qualifying training
as detailed in IRMER Schedule 2.
X-ray Images – Written Evaluation Policy
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Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
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8. REFERENCES AND ASSOCIATED DOCUMENTATION
1
Ionising Radiations (Medical Exposures) Regulations 2000. Statutory Instrument 2000 no 1059
http://www.opsi.gov.uk/si/si2000/20001059.htm
also
The Ionising Radiation (Medical Exposure) (Amendment) Regulations 2006 Statutory
Instrument 2000 No. 2523
http://www.opsi.gov.uk/si/si2006/20062523.htm
2
DOH Guidance for IRMER
[ARCHIVED CONTENT] The Ionising Radiation (Medical Exposure) Regulations 2000 (together
with notes on good practice) : Department of Health - Publications
3
RCR Guidelines – Making the Best Use of a Department of Clinical Radiology
Guidelines for Doctors. Sixth Edition
http://www.rcr.ac.uk/content.aspx?PageID=995
4
Portsmouth Plain Film Referral Guidelines
X-Ray Request Form
9. 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
Our values are the core of what Portsmouth Hospitals NHS Trust is and what we cherish. They
are beliefs that manifest in the behaviour our employees display in the workplace.
Our Values were developed after listening to our staff. They bring the Trust closer to its vision
to be the best hospital, providing the best care by the best people and ensure that our patients
are at the centre of all we do.
We are committed to promoting a culture founded on these values which form the ‘heart’ of our
Trust:
Respect and dignity
Quality of care
Working together
Efficiency
This policy should be read and implemented with the Trust Values in mind at all times.
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
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10. MONITORING COMPLIANCE WITH PROCEDURAL DOCUMENTS
Minimum requirement
to be monitored
Lead
Tool
Frequency of
Report of
Compliance
100% of
investigations /
treatments will have
written evaluation in
patient’s notes
CSC
Management
Team
Periodic
Audit
Annually
100% of
investigations /
treatments will have
Radiologists report
where required within
existing agreements
CSC
Management
Team
Periodic
Audit
Reporting
arrangements
Lead(s) for
acting on
Recommendatio
ns
Policy audit report
to:
 Annually IRMER
Group
Annually
Policy audit report
to:
 Annually IRMER
Group
Janine Hatch
Imaging
Services
Manager
Janine Hatch
Imaging
Services
Manager
This document will be monitored to ensure it is effective and to assurance compliance.
The effectiveness in practice of this Written Evaluation of X-rays Policy will be routinely
monitored (audited) to ensure the document objectives are being achieved. The standards
against which such audits are undertaken are defined in section 6 – Process.
In addition:




Additional entitlements to non-medical referrers will be developed by the Radiology
department and confirmed in IRMER Standard Operating Procedures through the
Radiology IRMER Group
Exceptions will be identified and reviewed by the Radiology IRMER Group and where
significant reported to Patient Safety Steering Group in the IRMER compliance report.
Adverse incident forms will be raised for significant non-compliances. All incidents
involving ionising radiation exposure are reviewed by the Trust Radiation Protection
Adviser and where required, notified to the Care Quality Commission according to
requirements of IRMER legislation.
The Medical Radiation Committee will be responsible for receiving the results and
monitoring action plans as required.
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
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APPENDIX 1:
PHT Radiology departments, other departments and procedures supported with X-ray
equipment
This appendix lists the Portsmouth Hospitals facilities to which this policy applies for
radiological procedures.
Radiology departments at
 Queen Alexandra Hospital (QAH)
o Emergency Department at QAH
o Dental Units at QAH
o Paediatric Department
o RDCU
o X-ray and scanning



Gosport War Memorial
Petersfield Hospital
Fareham Community Hospital

Radiographic procedures on wards and in theatres using mobile Xray equipment at QAH

Fluoroscopy assisted procedures in theatres and in departments
using mobile C-arm image intensifier systems at QAH
Fluoroscopy assisted procedures using permanently installed
equipment, or mobile equipment owned by specialties, e.g.
Cardiology, Orthopaedics, Radiotherapy


Radiographic procedures undertaken with a department’s own Xray equipment, e.g. Orthodontics/Maxillofacial, Nuclear Medicine,
Radiotherapy.

Breast screening and breast imaging procedures undertaken with
mammographic equipment in mobile trailers as part of the
Portsmouth Breast Screening programme

Radiotherapy treatment planning simulators, CT scanning, and
portal imaging devices

CT scanning equipment installed at QAH

Any additional facility leased, owned or rented by Portsmouth
Hospitals is support of its own clinical activity.
In addition to the above, this policy shall also apply to individual procedures undertaken by
any other organization where a specific arrangement has been made for patients under the
care of Portsmouth Hospitals NHS Trust.
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
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APPENDIX 2
PHT Radiology reporting schedule and specialty arrangements
The following investigations and procedures are all the responsibility of Portsmouth Hospitals
Radiology department Radiologists;







CT
Interventional procedures undertaken in the X-ray departments at QAH
Fluoroscopy procedures undertaken in the X-ray department at QAH (may also be
undertaken by an Advanced Practitioner Radiographer)
All General Practitioner imaging procedures referred directly to Radiology
Emergency Department radiography (may also be undertaken by a reporting radiographer)
Paediatric procedures undertaken in the radiology department (appendix 1) (may also be
undertaken by a reporting radiographer)
All imaging requested by Non-medical referrers.
General adult in and out patient films will not be routinely reported by a Radiologist. Reference
should be made to the PHT Plain Film Reporting and Evaluation Policy which discusses this in
detail.
This list may be added to by agreement with the relevant speciality
Unreported inpatient films can be discussed in the Radiology Access Unit (RAU), at regular
MDT or clinico-radiological meetings. To avoid unnecessary interruptions to Radiologists in the
RAU with attendant risk of errors and reduced efficiency, routine requests for opinions on
inpatient or outpatient images can be made by emailing
X-ray.scanningresults@porthosp.nhs.uk This group mailbox is reviewed regularly
throughout the day and images added to the PACS HOTSEAT worklist for Radiologist review.
Clinicians can also request a Radiological report on images by completing a ‘Request for
Report on Plain X-ray’ form, available at the reception desk in Radiology Day Case Unit at
QAH.
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Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
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APPENDIX 3
Specialties with arrangements for medical staff to undertake the role of IRMER Practitioner
The following specialties are responsible for the documentation of the evaluation of the
radiological procedures, other than those where a referral is made directly to PHT Radiology
services. Specialty Consultants undertake the role of IRMER Practitioner for their field by virtue
of eligible training (also section 8) and/or local agreement.








Radiotherapy / Oncology
Cardiology
Respiratory Medicine
Pain Clinic
Gastroenterology
Orthopaedics (use of Fluoroscan only)
Urology
General and Vascular Surgery
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
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APPENDIX 4
Exceptions:
The following lists those radiological procedures where a documented evaluation is not
required;

Individual fluoroscopy and electronic radiographic images taken as part of a complex
procedure where the information is used to assist a surgical intervention. However the
outcome of the procedure must be recorded, and which may include reference to any final
image taken for verification or for the patient records.

CT fluoroscopy procedures undertaken as part of an interventional procedure. However the
outcome of the procedure must be recorded, and which may include reference to any final
image taken for verification or for the patient records.

Procedures aborted owing to patient or technical factors where no useful information could be
obtained. A record must however be made of the fact that the procedure could not be
successfully completed.

Repeat radiographs as a result of patient or technical factors where image quality is
inadequate for the purpose of the procedure.

Films or images taken as part of planning a subsequent procedure, e.g. CT ‘scanogram’, testshots for subtraction Angiography

Films or images marked up for the purpose of planning subsequent treatment or intervention,
including also images for radiotherapy treatment planning. A marking on the image and
demonstrable use of the data is sufficient to demonstrate compliance.

Examinations undertaken where results are analyzed by computer and retained in storage
systems with the original procedure data, e.g. Dual-energy X-ray Absorptiometry scans
(DEXA scans) for osteoporosis.
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
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APPENDIX 5
Access to Radiologists - Radiologist Availability




Monday to Friday: RAU 0900 -1700 In the main x-ray dept (RDCU) QAH
Saturday and Sunday: 09:00-17:00 – Radiologist available on QAH site – contact via CT.
Out of hours – On-call Radiologist at the request of a senior clinician.
Community sites – Urgent cases via PACS and request to radiologist at QAH.
X-ray Images – Written Evaluation Policy
Version: 4
Issue Date: 13 February 2015
Review Date: 12 February 2016 (unless requirements change)
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