Information Package - Online Masters - Nursing, Sport

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POLICY UNDER REVIEW Please note that this policy is under review. It does, however, remain current Trust policy subject to any recent legislative changes, national policy instruction (NHS or Department

of Health), or Trust Board decision. For guidance, please contact the Author/Owner.

Document Title Clinical Guideline for the Reporting of Clinical Imaging Examination and Procedures

Date Issued/Approved: 30 September 2013

Date Valid From: 30 September 2013

Date Valid To: 30 June 2017

Directorate / Department responsible (author/owner): Dr P Cook, Speciality Lead, Clinical Imaging

Contact details: 01872 252285

Brief summary of contents This guideline relates to the content and delivery of reporting of radiographic imagesor procedures undertaken by the clinical imaging team.

Suggested Keywords: x-ray, reporting, radiologists, imaging

Target Audience RCHT PCH CFT KCCG

Executive Director responsible forPolicy: Medical Director

Date revised: This document replaces (exact title ofprevious version):Approval route (names ofcommittees)/consultation: Clinical Imaging Clinical Governance

Divisional Manager confirming approval processes Divisional Manager

Name and Post Title of additional signatories Signature of Executive Director giving approval {Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Clinical / Clinical Imaging

Links to key external standards Ionising Radiation (Medical Exposure) Regulations

Related Documents: RCHT Radiation Safety Policy

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Training Need Identified? No

This document is only valid on the day of printing Controlled Document

This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the

express permission of the author or their Line Manager.

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Clinical Guideline for the Reporting of Clinical Imaging Examination and Procedures Page 1 of 11

CLINICAL GUIDELINE FOR THE REPORTING OF CLINICAL IMAGING EXAMINATIONS AND PROCEDURES

1.0 Aim & Purpose This document is applicable to the reporting of imaging and procedures undertaken by the

Clinical Imaging Team. It is inclusive of formal reporting and red dot reporting but excludes

obstetric reporting as part of the NHS Foetal Anomaly Screening Programme. The

purpose of the document is to clarify the level of image interpretation and the staff groups

involved. The document also provides guidance on the structure and content of reporting.

2.0 The Guidance

2.1 Responsibilities

According to documentation from the Royal College of Radiologists (2012):

It is the responsibility of the reporting practitioner to ensure that the reports are

timely, clear and precise; to clearly document advice on further management or

action, where appropriate; and ensure the urgency for action is documented

within the content of the report.

It is the responsibility of the referrer/referring team to read and act upon the

result of every investigation it generates

2.2 Definitions

Reporting: Reporting describes the provision of a clinical opinion through

consideration of the medical history, presenting signs and symptoms declared by the

referrer, the appropriateness/ limitations of the imaging method, and observation and

description of normal and abnormal findings to enable the referring practitioner to

make an informed decision regarding patient management.

The Royal College of Radiologists gives the following definitions:

Critical Findings: Where emergency action is required as soon as possible

Urgent Findings: Where medical evaluation is required within 24 hours

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Significant Unexpected Findings: Where the reporting practitioner has concerns

that the findings are significant for the patient and may be unexpected by the referrer.

2.3 Staff Groups

2.3.1 Reporting Practitioners

Consultant Radiologists

Specialist Registrars

Consultant GI Radiographer acting within approved scope of practice (CI.IR.04

& CI.IR.01)

Consultant Breast Imaging Radiographer acting within approved scope of

practice (CI.MER.01)

Sonographers acting in accordance with local protocols (CI.US)

Advanced Practitioners (Reporting Radiographers) in plain film reporting acting

within agreed scope of practice (CI.TAG.07)

MRI practitioners who exclude intra orbital foreign bodies (refer to 2.7.2)

2.4 Structure and Content of Reports

A report is an assessment of the examination/procedure and may also include advice

regarding patient management. According to the Royal College of Radiologists

(2006) the usual format of reports will include:

Clinical details

A description of the findings

A conclusion or interpretation of findings in the clinical context

For long or complex reports there should be a conclusion at the end of the

report which answers the clinical question in the request

2.4.1 Quality, Accuracy and Verification of Reports

Each reporting practitioner is responsible for the quality and accuracy of their work.

Reports are generated using voice recognition (VR) or typed directly onto the

Computer Radiology Information System (CRIS). It is the responsibility of the

practitioner to check accuracy and readability before verifying the report. The report

is then released to CRIS, InSight PACS (including InSight Web), MAXIMS and the

patient’s GP practice.

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Consultant Radiologists are viewed as the experts and all practitioners must refer to

them where any doubt exists and a second opinion is needed. Non-medical reporters

receive specific, specialist training to prepare them for the role. As part of this

assessment a Consultant Radiologist verifies reports during both training and a

supervised period following qualification. A Consultant Radiologist has the authority

to check and verify reports of all non- medical practitioners.

2.5 Communication of Findings & Safety Net Procedures.

Each referrer/referring team is responsible for reading and acting upon the result of

every investigation they generate (RCR, 2012 & NPSA 2007).

It is the responsibility of the Reporter to ensure that the referring Clinician, or another

appropriate member of the clinical team is contacted if they consider that there is a

danger of unexpected relevant information contained in the report not being acted

upon (RCR, 2012).

All reports are constructed on CRIS and once verified, are automatically

communicated to the referrer electronically, via the InSight Web, Clinical Care and

Maxims systems; electronic reports are also sent to GPs via the GP link. Paper

copies (known as white copies) are currently sent to Consultants, Wards and the

Emergency Department; however this practice is reducing due to electronic systems.

For reports which contain Critical, Urgent, or Unexpected Significant findings, the

following additional Safety Net procedures should be followed.

2.5.1 Critical Findings

For immediately life-threatening conditions (e.g. life-threatening intracranial

haemorrhage, tension pneumothorax), where emergency action is required as soon

as possible, the referring clinician or an appropriate member of their team should be

notified directly by telephone or in person.

2.5.2 Urgent Findings

For true on call/emergency cases the referring doctor has a responsibility to pursue

and review the result, given that by definition the patient’s acute management will be

determined by the result of the scan e.g. head injury scan from A&E. Nevertheless,

for urgent conditions where medical evaluation is required within 24 hours, and, in

the clinical judgement of the reporter, there is a concern that the report will not be

viewed in a timely manner (e.g. incidental pulmonary embolus discovered on an

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inpatient CT before a weekend, or on an outpatient referral) the reporter or delegated

deputy should notify the referrer/referring team of the report.

2.5.3 Unexpected Significant Findings

For unexpected findings which do not require an urgent change in management but

which are very important for the future care of the patient. (e.g. incidental lung cancer

on CXR performed for an unrelated indication), it is the responsibility of the reporting

practitioner or their nominated deputy to bring the report to the referrer/referring

team’s attention if, in their clinical judgement, there is a danger that the report will not

be viewed in a timely manner. The reporter may recommend the next actions

following such a finding (i.e. in this example referral to a chest physician) but must

not take responsibility for such referrals or the ordering of further examinations; the

accountability lies with the team managing the patient’s care.

The communication of unexpected significant results may be delegated to a member

of the Clinical Imaging Administration Team at the judgement of the reporter.

For all MIU referrals with unexpected significant findings, the reporting clinician

should take appropriate measures in order to ensure that the patient’s GP is notified.

2.5.4 Recording communication of results.

Where results are communicated verbally to the referrer or an appropriate member of

their team by the reporter, the telephoned result should be recorded on the report as

an addendum, giving the date, time, name and role of the person who received the

report.

Where communication of results is delegated to the Clinical Imaging Administration

Team, the report should be placed in the ‘Admin Action’ folder on InSight Web, along

with a brief description of the action required. The Administration Team log the

following details from these actions in an Excel database:

Patient name

CR number

Procedure

Reporter

GP/Consultant’s Team/Ward

contact details

Date & time of communication

PA who made the telephone

call

Any additional comments

A note of the telephone communication is also made in the comments box on the

patient’s CRIS record.

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2.5.5 Communicating Findings Directly with the Patient

The communication of results with the patient must be sensitive and honest. Results

should only be discussed if the images have been fully reviewed and the individual

feels competent and it is appropriate to inform the patient including answering any

questions regarding ongoing care/management.

2.6 Reporting Images of the Deceased

Deceased paediatric patients (17 years and under): investigations must be reported.

Deceased adult patients (aged 18 and over): the investigations will not be analysed.

The following statement will be placed with the image(s).

'Patient deceased at the time of reporting; if you require these images to be reported

please contact the x-ray dept.'

The department will review images by request.

2.7 Images Which Do Not Receive Clinical Evaluation by the Imaging Department

It is a statutory requirement of IR(ME)R that all examinations involving ionising

radiation are evaluated in the clinical record, either in the form of a report by a

Radiologist or an opinion by another clinician.

2.7.1 Reporting Arrangements in Other Specialities

By agreement with the relevant clinical specialities the following examinations will not

be routinely reported by the clinical imaging department and the clinician's evaluation

of the examination will be documented in the patient's clinical record:

1) Non-paediatric orthopaedic plain radiographs from Orthopaedic wards, theatres

and outpatient clinics including fracture clinic. EXCEPTIONS: chest and abdominal

radiographs, requests from Physiotherapist and other non-medical practitioners.

2) Orthodontic examinations (OPG and occlusal views) requested by the orthodontic

department

The referring team can specifically request a radiologist report on any examination. If

this is made at the time of request the examination should be allocated to REFHOT.

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2.7.2 Pre- MRI Intra-Orbital Foreign Body Images

For radiographs to exclude the presence of foreign bodies within the eye which may

prohibit the patient from undergoing an MRI scan, MRI practitioners who have been

deemed competent will provide a report related to the presence of foreign body only.

Further reporting is available by request.

2.8 Location and Storage

2.8.1 Reports

All Clinical Imaging reports are held on the Computer Radiology Information System

(CRIS) and are available to view on the InSight Web system with the exception of

NHS Foetal Anomaly Screening.

2.9 References

National Patient Safety Agency (2007) Safer Practice Notice 16: Early

Identification Of Failure To On Radiological Imaging Reports.

Accessed at:

http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61469&..

Royal College of Radiologists (2006) Standards for the Reporting and

Interpretation of Imaging Investigations. London: RCR.

Accessed at:

http://www.rcr.ac.uk/docs/radiology/pdf/StandardsforReportingandInetrpwebvers.pdf

Royal College of Radiologists (2012) Standards for the Communication of Critical,

Urgent and Unexpected Significant Radiological Findings (2nd Edition). London:

RCR.

Accessed at: http://www.rcr.ac.uk/docs/radiology/pdf/BFCR(12)11_urgent.pdf

Royal College of Radiologists (2011) Standards and Recommendations for the

Reporting and Interpretation of Imaging Investigations by Non-Radiologist

Medically Qualified Practitioners and Teleradiologists. (2nd Edition) London:

RCR.

Accessed at: http://www.rcr.ac.uk/docs/radiology/pdf/BFCR(11)2_Reporting.pdf

http://www.nrls.npsa.nhs.uk/EasySiteWeb/getresource.axd?AssetID=61469&

http://www.rcr.ac.uk/docs/radiology/pdf/StandardsforReportingandInetrpwebvers.pdf

http://www.rcr.ac.uk/docs/radiology/pdf/BFCR(12)11_urgent.pdf

http://www.rcr.ac.uk/docs/radiology/pdf/BFCR(11)2_Reporting.pdf

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3.0 Monitoring compliance and effectiveness Element to be

monitored Reporting standards

Lead Dr P. Cook

Tool Audit of reporting accuracy within imaging & audit of documented

evaluation by departments outside of imaging.

Frequency Annual

Reporting

arrangements Report to clinical imaging audit meeting

Acting on

recommendations

and Lead(s)

The lead will act on urgent findings immediately, any discussions/

recommendation will be documented through the minutes of the

clinical imaging audit meeting.

Change in

practice and

lessons to be

shared

Actions will be taken by the Lead, changes in practice will be

reflected within this document. Lessons learned will be shared and

implemented through the clinical imaging audit meeting.

4.0 Equality and Diversity This document complies with the Royal Cornwall Hospitals NHS Trust service Equality and

Diversity statement.

4.1Equality Impact Assessment

The Initial Equality Impact Assessment Screening Form is at Appendix 2.

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Appendix 1. Governance Information

Document Title

Clinical Guideline for the Reporting of Clinical Imaging Examination and Procedures CI.GEN.19

Date Issued/Approved: 30 September 2013

Date Valid From: 30 September 2013

Date Valid To: 1st September 2016

Directorate / Department responsible (author/owner):

Dr P. Cook, Speciality Lead, Clinical Imaging

Contact details: 01872 252285

Brief summary of contents

This guideline relates to the content and delivery of reporting of radiographic images or procedures undertaken by the clinical imaging team.

Suggested Keywords: X-ray, reporting, radiologists, imaging

Target Audience RCHT PCT CFT

Executive Director responsible for Policy:

Medical Director

Date revised: June 2016

This document replaces (exact title of previous version):

Clinical Guideline for the Reporting of Clinical Imaging Examination and Procedures

Approval route (names of committees)/consultation:

Clinical Imaging Clinical Governance

Divisional Manager confirming approval processes

Bruce Daniel, Divisional Manager

Name and Post Title of additional signatories

Emma Spouse, Diagnostics Lead

Signature of Executive Director giving approval

{Original Copy Signed}

Publication Location (refer to Policy on Policies – Approvals and Ratification):

Internet & Intranet Intranet Only

Document Library Folder/Sub Folder Clinical / Clinical Imaging

Links to key external standards Ionising Radiation (Medical Exposure) Regulations

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Related Documents: RCHT Radiation Safety Policy

Training Need Identified? No

Version Control Table

Date Version No

Summary of Changes Changes Made by (Name and Job Title)

Nov 11 V1.0 Initial Issue Naomi Burden Governance Radiographer

18/6/2013 V2.0 Updated to reflect changes in imaging PACS system

Naomi Burden Governance Radiographer

27/8/2013 V3.0 Updated document to include reports excluded from the document.

Naomi Burden Governance Radiographer

All or part of this document can be released under the Freedom of Information Act 2000 This document is to be retained for 10 years from the date of expiry. This document is only valid on the day of printing Controlled Document This document has been created following the Royal Cornwall Hospitals NHS Trust Policy on Document Production. It should not be altered in any way without the express permission of the author or their Line Manager.

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Appendix 2.Initial Equality Impact Assessment Screening Form

*Please see Glossary

7. The Impact Please complete the following table.

Are there concerns that the policy could have differential impact on: Equality Strands: Yes No Rationale for Assessment / Existing Evidence

Age x There is no impact on this group

Sex (male, female, trans-

gender / gender reassignment)

x There is no impact on this group

Race / Ethnic communities /groups


Clinical Guideline for the Reporting of Clinical Imaging Examination and Procedures CI.GEN.19

Directorate and service area: Clinical Imaging

Is this a new or existing Procedure? Existing

Name of individual completing assessment: Naomi Burden

Telephone: 01872255086

1. Policy Aim*

To clarify reporting processes for imaging examinations and procedures.

2. Policy Objectives*

To ensure the reporter fully understands their responsibilities when requesting medical imaging.

3. Policy – intended Outcomes*

Clear standards in place o Local document which reflects the requirements of the law in relation to ionising radiation

2 How will you measure the outcome?

Through audit and monitoring

5. Who is intended to benefit from the Policy?

Staff and patients

6a. Is consultation required with the workforce, equality groups, local interest groups etc. around this policy? b. If yes, have these groups been consulted? c. Please list any groups who have been consulted about this procedure.

No

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Disability - learning disability, physical disability, sensory impairment and mental health problems


Religion / other beliefs


Marriage and civil partnership


Pregnancy and maternity x There is no impact on this group

Sexual Orientation, Bisexual, Gay, heterosexual, Lesbian


You will need to continue to a full Equality Impact Assessment if the following have been highlighted:

You have ticked “Yes” in any column above and

No consultation or evidence of there being consultation- this excludes any policies which have been identified as not requiring consultation. or

Major service redesign or development

8. Please indicate if a full equality analysis is recommended. Yes No

9. If you are not recommending a Full Impact assessment please explain why.

Signature of policy developer / lead manager / director Date of completion and submission

Names and signatures of members carrying out the Screening Assessment

1. 2.

Keep one copy and send a copy to the Human Rights, Equality and Inclusion Lead, c/o Royal Cornwall Hospitals NHS Trust, Human Resources Department, Knowledge Spa, Truro, Cornwall, TR1 3HD A summary of the results will be published on the Trust’s web site. Signed _______________ Date ________________