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12.5 Policies and procedures

The service must have dated, written policies and procedures to provide the framework for the service being provided. These must be based on current knowledge and principles. To achieve the standard the following must be observed:

  • policies and procedures are reviewed and updated at least annually and should be signed by all involved in the service and dated accordingly
  • diagnostic imaging and interventional procedures using ionising radiation are performed only upon written request from an approved referral source or follow published self-referral policies. The request must contain sufficient clinical information to justify the examination (see also section 12.3 on referrals)
  • a written ‘intimate examinations and chaperone’ policy should be in place. It is good practice to offer a suitable chaperone for all intimate procedures; this should be irrespective of the healthcare professional’s gender. The SCoR has published a guidance document on intimate examinations and the use of chaperones27
  • all images are interpreted and reported in a timely fashion within an agreed scheme of work
  • protocols relating to all imaging and interventional procedures are available
  • procedures and protocols as required under the Ionising Radiation Regulations and subsequent amendments must be available. In case of abnormal findings, there should be a policy on referring patients and clients into appropriate care management pathways in a timely fashion. There must be a written policy for dealing with results of a critical or urgent nature 28
  • where cases are complex or equivocal there should be a mechanism for obtaining a second opinion. In situations where interpretation is not or cannot be provided, this is identified and an appropriate procedure is agreed with the referrer 
  • in the event of an adverse incident, individual statements must be written and dated by all concerned as soon as possible after the event. These will be important in internal/external enquires that may follow.

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