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STANDARD OPERATING PROCEDURE FOR RADIATION PROTECTION

STANDARD OPERATING PROCEDURE FOR RADIATION PROTECTION


 The Department of radiology is open 7 days/24 hours with full coverage of 6 days a week including Saturdays with a skeleton crew on Sundays and holidays,

The CT and ultrasound section has an On-Call Technologist as needed during off-business hours, weekends and holidays.

Services of the department of radiology are the following: CT SCAN, ULTRASOUND, SPECIAL PROCEDURES, FLUOROSCOPY and GENERAL RADIOGRAPHY including PORTABLE X-ray for In- patients. ICU and C-arm machine in operating room.

GENERAL POLICIES

INPATIENT SERVICES

  1. All x-ray requests are encoded into the hospital computer system. Nursing staff call and informs the X-ray Technologist; Radiologic Technologist Request form should be properly filled up by the nurse or requesting physician and sent to the department.
  2. Routine procedures can be done anytime.
  3. Special procedures such as Barium Enema (BE), Upper GI Series (UGIS), Hysterogram, Kidney-Ureter-Bladder (KUB), Intravenous Pyelography (IVP), ERCP, etc. done by appointment.
  4. The department of radiology should be informed ahead of time about procedures to be done at OR that will require the use of the c-arm and portable machine.
  5. Before they are brought in, the department of radiology should be informed about emergency room patients who require radiology services. Initial management must be administered to any ER patient prior to any x-ray examination.
  6. The technologist who receives the phone call for “STAT” x-ray portable services should endorse the request to another technologist assigned to do portable x-ray procedures (at Ward, ICU, NICU, PICU, CCU and OR). The request form for such procedures should be received by the department following the phone call.
  7. Patient preparation for the different x-ray procedures are provided in each nurse station.
  8. The patient should be accompanied by a nurse / aide (with the patient’s chart) to the Department of Radiology.

ULTRASOUND/ CT SCAN

All procedures, especially those requiring bowel preparations are scheduled. The patient is provided with instructions for the bowel preparation. However, patients not previously scheduled are accommodated during the day depending on the bulk of the patients for the day.

  1. All in patients not initially included for the day’s schedule are placed on an “on call” procedure basis.
  2. Emergency examinations on requests for ultrasound outside of office hours or during holidays are done on “STAT” basis, and the consultant on deck for the day is requested to perform the procedure at the Radiology Department.
  3. Procedures requiring fasting are given the earlier time slots.
  4. Each patient is given a unique case number. The case numbers of patients who have undergone previous x-rays are retrieved from the files in the office computer. New patients are assigned new case numbers.
  5. All patients are billed accordingly, based on the approved hospital rates.
  6. Procedures of admitted patients are charged to their hospital accounts.
  7. The Radiology Department (X-ray section, CT scan, Ultrasound section) keeps its own patient record. The patient logbook should reflect the name of the patient, type of examination, date and time of the procedure and the case number.
  8. Patients are registered into the hospital’s computer and outsouced teleradiology system for interpretation of X-ray films. CT Scan and Ultrasound results are computerized.
  9. X-ray images, CT scan and ultrasound printouts are sent to the radiologist for official interpretation. For ultrasound, the radiologist on duty scans the patients prior to issuance of the result.
  10. Official reading of results of X-ray, and CT scans are outsourced from a private teleradiology company – the Media Archives, Philippines (MAPI) with whom the hospital has a public-private partnership (PPP). Ultrasound results are transcribed into a computer by ultrasound technicians.
  11. Radiologic technologists verify the printout of the official reading results before releasing the same to the patients. Two copies of the results are provided, one for the patient and one for the radiology department’s record.
  12. X-Ray results are collected by the nurse on duty for inpatients. For out-patients results of x-rays and ultrasound should be picked up by the patient or their representatives within two (2) working days after the procedure. CT scan results are released in 3-7 days.

OUTPATIENT SERVICES

  1. Requests for the chest X-ray or X-rays of extremities and other routine procedures can be done without prior scheduling or bowel preparation.
  2. All X-ray requests should be properly filled-up by the requesting physician.
  3. Special procedures like Upper GI Series, Cholecystogram, Barium Enema, Intravenous Pyelography and others are done by appointment. Special X-ray Procedures start at 8:00 am.
  4. The patient calls or personally goes to the radiology department for scheduling.
  5. The Technologist provides instructions to the patient regarding the needed bowel preparation. A copy of the instruction is given to the patient.
  6. For intravenous pyelography, hypoallergenic dye is used.

OPERATING ROOM

  1. When x-rays are required at the OR suite, the technologist is required to be present during the surgery and to operate and maintain the radiology C-arm and portable machine.
  2. The technologist must return the portable equipment to the proper storage area.