Imaging Services Policy and Procedure Manual

MCN Healthcare’s ready-to-customize Imaging Services Policy and Procedure Manual provides everything you need to meet regulatory compliance (CMS, TJC and NIAHO) and addresses all aspects of the Imaging Services Department, including Diagnostic, CT, Mammography, MRI, Nuclear Medicine and Ultrasound! With over 400 policies, procedures and forms, this comprehensive manual gives you the templates you need so you don't have to re-invent the wheel.

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ChangesTable of Contents - TJC Standards and CMS RegulationsTable of Contents - NIAHO Standards and CMS RegulationsCopyrightDisclaimerApproval/Signature SheetIntroduction
SECTION 02 - ENVIRONMENT OF CARE
Radiation Safety
2101 - Diagnostic Imaging Radiation Safety Program2102 - Structural Shielding Design Assessment and Radiation Protection Survey2103 - Radiation Safety - Patient and Employee2104 - Pregnant Staff2105 - Occupational Dose Limits2106 - Radiation Exposure Monitoring of Staff2107 - Radiation Monitoring Badge2108 - Lost Film Badge Report Form2109 - New Employee or Previous Occupational Exposure Records Request Form2110 - Recommended Operating Procedures for Medical X-Rays2111 - Reducing Radiological Exposure in the Perioperative Setting2112 - Operating Room Procedures for Imaging Services2113 - Radiation Safety for Nursing Staff When Inpatients Receive Radioactive Therapies2114 - Radiation Safety for Nursing Staff When Inpatients Have Diagnostic Examinations2115 - Radioactive Material Caution Signs and Labels2116 - Sign Posting Requirements2117 - General Radiation Safety - Radiopharmaceuticals2118 - Radiopharmaceutical Security During Transportation2119 - Vehicle Survey Procedures2120 - Vehicle Survey Log Form2121 - Delivery Staff Qualifications2122 - DOT Labeling Protocol - Radioactive Materials2123 - Radioactive Materials - Ordering, Receiving and Handling2124 - Incoming Radiopharmaceutical Survey Log Form2125 - Outgoing Radiopharmaceutical Wipe Test Form2126 - Total Amounts of Non-Sealed Radionuclides Form2127 - Mobile Radiopharmaceutical Log-in Procedures2128 - Radiopharmaceuticals Outgoing - Mobile Department2129 - Daily Nuclear Medicine Technologist Log Form2130 - Hot Lab Regulations2131 - Radioactive Xenon Gas - Procedures and Precautions2132 - Sealed Sources - Procedures and Precautions2133 - Disposal Procedures - Waste Pick-up Protocol2134 - Nonradioactive Trash Survey Log Form2135 - Minor Spills of Radiopharmaceuticals2136 - Decontamination Kit2137 - Emergency Procedures - Radioactive Materials2138 - Emergency Radioactive Spill Procedures2139 - Radiopharmaceutical Security of the Nuclear Medicine Department2140 - Restricted and Unrestricted Areas2141 - Restricted Area Survey Procedures2142 - Restricted Area Survey Log - GM Survey Only2143 - Restricted Area Survey Log - Wipe Test2144 - External Office Protection Procedure2145 - Recording Policies - Hot Lab2146 - Basic Work Area Protection Procedures2147 - Radiation Safety and Protection for Non-Nuclear Staff2148 - Restricted Area Staff Monitoring Procedures2149 - Visitor Protection Procedures2150 - Visitor and Staff Monitoring Log Form
SECTION 03 - HUMAN RESOURCES
3001 - Position Description/Performance Evaluation - Imaging Services Manager3002 - Performance Evaluation - Population-Specific/Age-Related Competency - Imaging Services Manager3003 - Annual Competency Clinical Skills Assessment - Imaging Services Manager3004 - Position Description/Performance Evaluation - Imaging Services Technologist3005 - Performance Evaluation - Population-Specific/Age-Related Competency - Imaging Services Technologist3006 - Annual Competency Clinical Skills Assessment - Imaging Services Technologist3007 - Position Description/Performance Evaluation - CAT/MRI Technologist3008 - Performance Evaluation - Population-Specific/Age-Related Competency - CAT/MRI Technologist3009 - Annual Competency Clinical Skills Assessment - CAT/MRI Technologist3010 - Position Description/Performance Evaluation - Ultrasound Technologist3011 - Performance Evaluation - Population-Specific/Age-Related Competency - Ultrasound Technologist3012 - Annual Competency Clinical Skills Assessment - Ultrasound Technologist3013 - Position Description/Performance Evaluation - Nuclear Medicine Chief Technologist3014 - Performance Evaluation - Population-Specific/Age-Related Competency - Nuclear Medicine Chief Technologist3015 - Annual Competency Clinical Skills Assessment - Nuclear Medicine Chief Technologist3016 - Position Description/Performance Evaluation - Nuclear Medicine Technologist3017 - Performance Evaluation - Population-Specific/Age-Related Competency - Nuclear Medicine Technologist3018 - Annual Competency Clinical Skills Assessment - Nuclear Medicine Technologist3019 - Position Description/Performance Evaluation - Imaging Services Assistant3020 - Performance Evaluation - Population-Specific/Age-Related Competency - Imaging Services Assistant3021 - Annual Competency Clinical Skills Assessment - Imaging Services Assistant3022 - Position Description/Performance Evaluation - Imaging Services Transcriptionist3023 - Annual Competency Skills Assessment - Imaging Services Transcriptionist3024 - Position Description/Performance Evaluation - Imaging Services Receptionist/Clerk3025 - Performance Evaluation - Population-Specific/Age-Related Competency - Imaging Services Receptionist/Clerk3026 - Annual Competency Skills Assessment - Imaging Services Receptionist/Clerk3027 - Imaging Services - Digital Imaging Systems Competency Form3028 - Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol3029 - Staff Qualifications and Competency3030 - Radiological Modalities3031 - Certification of Technologist3032 - Mammography Technologist Restrictions3033 - New Employee Orientation3034 - Departmental Orientation3035 - Ongoing Education and Training - Imaging Services3036 - Inservice Program Method3037 - Inservice Program Documentation3038 - Imaging Services Staff Checklist3039 - Continuing Education - Technologist3040 - Certification and Continuing Education - Sample Memo3041 - CPR Certification3042 - Dress Code
SECTION 08 - PROVISION OF CARE, TREATMENT AND SERVICES
Patient Care
8001 - Ordering Exams8002 - Nuclear Medicine - Ordering of8003 - Scheduling Procedures8004 - Scheduling Outpatient Examinations8005 - Scheduling Multiple Examinations8006 - STAT Diagnostic Radiological Procedures8007 - Availability of STAT Scanning Services8008 - Procedure for After Hours, Weekend or Emergency Scans8009 - Preparing Imaging Services Requests8010 - Patient Identification for Clinical Care and Treatment8011 - Assessment of Patients8012 - Fall Prevention8013 - Latex Sensitive Patient - Care of8014 - Latex and Non-Latex Alternatives8015 - Invasive Procedure Site Identification (Outside of the OR)8016 - Radiology Time Out Checklist - Identification/Time Out/Site Marking8017 - Critical Results of Tests and Diagnostic Procedures - Reporting of8018 - Critical Test Results - Imaging Services8019 - Critical Test Results Form8020 - "Hand-Off" Communication8021 - Filming8022 - Bariatric Patients - Imaging of8023 - Patient Weight Limitations8024 - Critical/Unstable Patients - Care of8025 - Emergency Patients or Patients Who Become Unstable - Care of8026 - Respirator/Monitor Patients8027 - CAT Scan Exams - Patient Preparation8028 - CAT Scan Procedure8029 - CT Scans in Patients with Electronic Medical Devices8030 - Computerized Tomography (CT) Procedure in California8031 - MRI Scan Exams - Patient Preparation8032 - MRI Patient Screening8033 - MRI Patient Screening Tool8034 - MRI Patient Safety8035 - List of Ferromagnetic Objects8036 - MRI - Patient Scan Protocols8037 - MRI Scan Procedure8038 - Nuclear Medicine Studies - Patient Preparation8039 - Inpatient Test Preparations8040 - Pregnant Patients - Radiological Examination8041 - Patient Recall for Diagnostic Imaging8042 - Patient Shielding8043 - Patient Transportation to/from Imaging Services8044 - Moving Patient to Scanning Table8045 - Portable X-Ray Unit8046 - Cardiopulmonary Resuscitation Protocol8047 - Cardiac Arrest Procedure in Imaging Services8048 - Emergency Crash Carts8049 - Emergency Crash Cart Security and Accountability8050 - Emergency Medications8051 - Contrast Reaction8052 - No Code Orders8053 - Patient Sedation8054 - Sedation8055 - Sedation Monitoring Form8056 - Patient and Family Education8057 - Patient and Family Education Handout - Participate In Your Healthcare
SECTION 11 - PROTOCOLS