Imaging Services Policy and Procedure Manual
Imaging Services Policy and Procedure Manual
About this Manual
Imaging Services Policy and Procedure Manual is a manual containing many of our policy and procedure templates for the medical office, hospital, and other healthcare organizations. The policies cover: Joint Commission (JCAHO or TJC) • CMS • HIPAA • CDC • AAAHC and more.Want access to all our manuals? Click here
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SECTION 01 - EMERGENCY MANAGEMENT
SECTION 02 - ENVIRONMENT OF CARE
General Department Policies
2001 - Floor Plan Evaluation2002 - Imaging Services Department Safety2003 - Patient Safety2004 - Staff Safety2005 - Staff Injury and Illness2006 - No Smoking Policy2007 - Hazardous Materials and Waste - General Radiation Safety2008 - How to Read Safety Data Sheets (SDS)2009 - How to Read MSDS2010 - Radioactive Waste Disposal2011 - Silver Recovery2012 - Quench Evacuation2013 - Fire Safety - Imaging Services2014 - Use of a Fire Extinguisher2015 - Electrical Safety and Maintenance2016 - Electrical Extension Cords
Radiation Safety
2101 - Diagnostic Imaging Radiation Safety Program2102 - Radiation Safety - Patient and Employee2103 - General Radiation Safety - Radiopharmaceuticals2104 - Radiation Safety for Nursing Staff When Inpatients Receive Radioactive Therapies2105 - Radiation Safety for Nursing Staff When Inpatients Have Diagnostic Examinations2106 - Dosage Units2107 - Radioactive Material Caution Signs and Labels2108 - Sign Posting Requirements2109 - Recommended Operating Procedures for Medical X-Rays2110 - Radiopharmaceutical Security of the Nuclear Medicine Department2111 - Restricted and Unrestricted Areas2112 - Restricted Area Survey Procedures2113 - Restricted Area Survey Log - GM Survey Only2114 - Restricted Area Survey Log - Wipe Test2115 - External Office Protection Procedure2116 - Recording Policies - Hot Lab2117 - Basic Work Area Protection Procedures2118 - Radiation Safety and Protection for Non-Nuclear Staff2119 - Radioactive Material Action Levels2120 - Radiation Exposure Monitoring of Staff2121 - Radiation Monitoring Badge2122 - Lost Film Badge Report Form2123 - New Employee or Previous Occupational Exposure Records Request Form2124 - Restricted Area Staff Monitoring Procedures2125 - Visitor Protection Procedures2126 - Visitor and Staff Monitoring Log Form2127 - Reducing Radiological Exposure in the Perioperative Setting2128 - Operating Room Procedures for Imaging Services2129 - Radiopharmaceutical Security During Transportation2130 - Vehicle Survey Procedures2131 - Vehicle Survey Log Form2132 - Delivery Personnel Qualifications2133 - DOT Labeling Protocol - Radioactive Materials2134 - Procedures for Ordering, Receiving and Handling Radioactive Materials2135 - Incoming Radiopharmaceutical Survey Log Form2136 - Outgoing Radiopharmaceutical Wipe Test Log Form2137 - Total Amounts of Non-Sealed Radionuclides Form2138 - Mobile Radiopharmaceutical Log-in Procedures2139 - Radiopharmaceuticals Outgoing - Mobile Department2140 - Daily Nuclear Medicine Technologist Log2141 - Hot Lab Regulations2142 - Radioactive Xenon Gas - Procedures and Precautions2143 - Sealed Sources - Procedures and Precautions2144 - Disposal Procedures - Waste Pick-up Protocol2145 - Nonradioactive Trash Survey Log2146 - Decontamination Procedures2147 - Decontamination Kit2148 - Emergency Procedures - Radioactive Materials2149 - Emergency Radioactive Spill Procedures
Equipment and Preventive Maintenance
2301 - Preventive Maintenance2302 - Radiographic Equipment Care and Preventive Maintenance2303 - Evaluation of Site's Technologist - Quality Control Program Form2304 - Mechanical Safety - Imaging Services Equipment2305 - PM Equipment Inventory Form2306 - PM Service Record Form - Imager2307 - PM Service Record Form - Nuclear Medicine Camera2308 - Scanner Quality Control2309 - Scanner Service and Repair2310 - Equipment Management Program for MRI2311 - MR Max Planned Maintenance Schedule - GEMS Version A2312 - MR Max Planned Maintenance Schedule - GEMS Version B2313 - MR Max Planned Maintenance Schedule - GEMS Version C2314 - MR Max Planned Maintenance Schedule - GEMS Version D2315 - MR Max Planned Maintenance Schedule - GEMS Version E2316 - MR Max Planned Maintenance Schedule - GEMS Version F2317 - Nuclear Medicine Equipment Calibrations2318 - Survey Meter Calibration2319 - Stationary Camera Quality Check2320 - Mobile Camera Quality Check2321 - Xenon Delivery Systems2322 - Documentation of Equipment - Quality Control and Service Records2323 - Mammography Quality Control - Imaging Quality Test, Breast Phantom Imaging2324 - Mammography Quality Control - Retake Rate Analysis2325 - Mammography Quality Control - Darkroom Requirements2326 - Mammography Quality Control - Film Processor Testing2327 - Mammography Equipment Evaluation Form2328 - Medical Physicist's Mammography Quality Control Test Summary Form2329 - Emergency Generators2330 - Vehicle Inspection (Contracted Services)2331 - Trailer Preventive Maintenance (Contracted Services)2332 - Trailer Service and Repair (Contracted Services)2333 - Trailer Emergency Repair (Contracted Services)
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 - Performance Evaluation - Population-Specific/Age-Related Competency - Imaging Services Transcriptionist3024 - Annual Competency Skills Assessment - Imaging Services Transcriptionist3025 - Position Description/Performance Evaluation - Imaging Services Receptionist/Clerk3026 - Performance Evaluation - Population-Specific/Age-Related Competency - Imaging Services Receptionist/Clerk3027 - Annual Competency Skills Assessment - Imaging Services Receptionist/Clerk3028 - Annual Competency - Joint Commission National Patient Safety Goals and Universal Protocol3029 - Imaging Services - Digital Imaging Systems Competency Form3030 - Staff Qualifications and Competency3031 - Radiological Modalities3032 - Certification of Technologist3033 - Mammography Technologist Restrictions3034 - New Employee Orientation3035 - Departmental Orientation3036 - Inservices and Continuing Education3037 - Continuing Education - Technologist3038 - Certification and Continuing Education - Sample Memo3039 - Mandatory Inservice Meetings3040 - Voluntary Inservice Meetings3041 - Inservice Program Documentation3042 - Inservice Program Method3043 - Imaging Services Personnel Checklist3044 - CPR Certification3045 - Cross-Training Incentive3046 - Dress Code - General3047 - Dress Code - Specific to Imaging Services3048 - Employee Conduct3049 - Salary Criteria3050 - Pregnant Staff3051 - Pregnant Employee - CAT/MRI
SECTION 04 - INFECTION PREVENTION AND CONTROL
4001 - Infection Prevention and Control - Imaging Services4002 - Hand Hygiene - CDC Guidelines4003 - Standard Precautions4004 - Transmission-Based Precautions (Isolation Precautions)4005 - Personal Protective Equipment4006 - Asepsis4007 - Portable Imaging in an Isolation Room4008 - Patient on Transmission Precautions4009 - Use of Ultrasound Gel Products4010 - Sharps Injury Protection Plan4011 - Sharps Injury Log Form4012 - Handling of Biohazardous Waste4013 - Cleaning Imaging Services Department
SECTION 05 - LEADERSHIP
5001 - Scope of Services5002 - List of Exams5003 - Organizational Flowchart5004 - Imaging Services Department Organizational Chart5005 - Staffing Plan5006 - Duties of the Medical Director of Imaging Services5007 - Management Availability5008 - Supervisor Responsibilities5009 - Radiologist Availability5010 - Non-Radiologist Performing Fluoroscopy Procedures5011 - Radiation Physicist Services5012 - Contracted Imaging Services5013 - Availability of Scheduled Scanning Services (Contracted Services)5014 - Delays of Scanning (Contracted Services)5015 - Hospital/Mobile Unit Communication5016 - Policies and Procedures - General5017 - Revisions/Updates to Imaging Services Policy and Procedure Manual5018 - Telemedicine Services
SECTION 06 - MEDICATION MANAGEMENT
6001 - Patient Medication Information/Reconciliation6002 - Patient Medication Information/Reconciliation Form6003 - Floor Stock6004 - Refrigerated Medications in Imaging Services Department6005 - Medication Refrigerator Temperature Log Form6006 - Emergency Crash Carts6007 - Emergency Crash Cart Security and Accountability6008 - Emergency Medications6009 - Medication Administration6010 - Medication and Solution Administration - Invasive Procedure6011 - Contrast Media Administration6012 - Safe Medication Practices6013 - Oral and Rectal Contrast Media Administration6014 - Oral Contrast for Radiological Procedures 6015 - IV Contrast Agents - Administration 6016 - Administration of Contrast Agents to Dialysis Patients6017 - Administration of Drugs Intrathecally6018 - Certification for Radionuclide Administration6019 - Radiopharmaceutical Administration6020 - Radiopharmaceutical Medical Events6021 - Misadministration of a Radiopharmaceutical6022 - Diagnostic Misadministration Report Form6023 - Adverse Drug Reaction Reporting6024 - Adverse Drug Reaction Reporting Form (Internal)
SECTION 07 - PERFORMANCE IMPROVEMENT
7001 - Performance Improvement Plan 7002 - Imaging Services PI Monitoring and Evaluation Plan7003 - Imaging Services PI Trending Sheet7004 - Imaging Services PI Outcome Evaluation7005 - Imaging Services PI Volume Measures/Statistics7006 - Magnetic Resonance Imaging - Performance Improvement Program7007 - MRI Weekly System Status Report Form7008 - Daily Utilization Log Form7009 - MRI Demographic Report Form
SECTION 08 - PROVISION OF CARE, TREATMENT AND SERVICES
Patient Care
8001 - Scheduling Procedures8002 - Scheduling Outpatient Examinations8003 - Scheduling Multiple Examinations8004 - STAT Diagnostic Radiological Procedures8005 - Availability of STAT Scanning Services8006 - Procedure for After Hours, Weekend or Emergency Scans8007 - Preparing Imaging Services Requests8008 - Filming8009 - Patient Identification for Clinical Care and Treatment8010 - Reporting of Critical Results of Tests and Diagnostic Procedures8011 - Critical Test Results8012 - Critical Test Results Form8013 - Hand-Off Communication8014 - Ordering Exams8015 - Nuclear Medicine - Ordering of8016 - Assessment of Patients8017 - Fall Prevention8018 - Latex Sensitive Patient - Care of8019 - Latex and Non-Latex Alternatives8020 - Bariatric Patients - Imaging of8021 - Patient Weight Limitations8022 - Care of Critical/Unstable Patients8023 - Care of Emergency Patients or Patients Who Become Unstable8024 - Respirator/Monitor Patients8025 - CAT Scan Exams - Patient Preparation8026 - CAT Scan Procedure8027 - CT Scans in Patients with Electronic Medical Devices8028 - Computerized Tomography (CT) Procedure in California8029 - MRI Scan Exams - Patient Preparation8030 - MRI Patient Screening8031 - MRI Patient Screening Tool8032 - MRI Patient Safety8033 - List of Ferromagnetic Objects8034 - MRI - Patient Scan Protocols8035 - MRI Scan Procedure8036 - Nuclear Medicine Studies - Patient Preparation8037 - Inpatient Test Preparations8038 - Pregnant Patients - Radiological Examination8039 - Patient Recall for Diagnostic Imaging8040 - Patient Shielding8041 - Patient Transportation to/from Imaging Services8042 - Moving Patient to Scanning Table8043 - Portable X-Ray Unit8044 - Equipment for Emergency Patients8045 - Code Blue8046 - Cardiopulmonary Resuscitation Protocol8047 - Contrast Reaction and Cardiac Arrest Procedure8048 - No Code Orders8049 - Patient Sedation8050 - Sedation8051 - Sedation Monitoring Form8052 - Invasive Procedure Site Identification (Outside of the OR)8053 - Radiology Time Out Checklist - Identification/Time Out/Site Marking8054 - Patient and Family Education8055 - Patient and Family Education Handout - Participate In Your Healthcare
Mammography Services
8101 - Supervisor Responsibilities - Mammography8102 - Mammogram Scheduling Protocol8103 - Rules of Good Practice for Mammography8104 - Routine Mammographic Views and Image Identification8105 - Repeat Films/Magnification Views8106 - Implants and Dense Breasts8107 - Compliance Requirements8108 - Contents of Medical Records and Mammography Reports8109 - Communication of Results to Patients8110 - Record Keeping - Mammograms
Departmental Procedures
SECTION 09 - INFORMATION MANAGEMENT/RECORD OF CARE, TREATMENT AND SERVICES
9001 - Verbal and Written Orders - General9002 - Documentation and the Use of Abbreviations, Acronyms and Symbols9003 - Unacceptable Abbreviation and Symbol List9004 - Radiologist Signing of Reports9005 - Nuclear Medicine Reports - Signing of9006 - Retention of Radiology Medical Records9007 - Retention of Nuclear Medicine Medical Records9008 - Release of Patient Information9009 - Release of Patient Information Consent Form9010 - Picture Archiving and Communication System (PACS)9011 - General Security - Picture Archiving and Communication System9012 - Workforce Authorization - Picture Archiving and Communication System9013 - Physician Access to the Hospital's PAC System Web Server
SECTION 10 - RIGHTS AND RESPONSIBILITIES OF THE INDIVIDUAL
SECTION 11 - PROTOCOLS
The following documents are generic protocols
Diagnostic Radiology Protocols
11001 - Fingers11002 - Thumb11003 - Hand11004 - Wrist11005 - Supplementary Views of the Wrist - Carpal Canal11006 - Forearm11007 - Elbow11008 - Humerus - Proximal and Distal11009 - Shoulder11010 - Acromioclavicular Articulation11011 - Clavicle11012 - Sternoclavicular Joint11013 - Sternum11014 - Toes11015 - Foot11016 - Os Calcis (Calcaneus)11017 - Ankle11018 - Tibia-Fibula11019 - Knee11020 - Patella11021 - Femur11022 - Pelvis11023 - Hip11024 - Ribs11025 - Cervical Spine11026 - Thoracic Spine11027 - Lumbosacral Spine11028 - Sacroiliac Joints11029 - Sacrum11030 - Coccyx11031 - Postural Study11032 - Skull11033 - Sella Turcica11034 - Sinuses11035 - Mastoids11036 - Nasal Bones11037 - Facial Bones11038 - Orbits11039 - Mandible11040 - Single Abdomen - KUB11041 - Bone Age Study11042 - Metastatic Bone Study11043 - Scanogram11044 - Chest11045 - Orthocardiogram11046 - Abdominal Series11047 - Esophagus11048 - Upper GI Series11049 - Small Bowel Series11050 - Barium Enema - Single11051 - Air Contrast Barium Enema11052 - Cholecystography11053 - T-Tube Cholangiogram11054 - KUB11055 - IVP11056 - Infusion Pyelogram11057 - Cystogram11058 - Metrizamide Myelogram11059 - Aspiration of Joints or Bursal Collections11060 - Temporary Pacemaker Insertion11061 - Percutaneous Transhepatic Cholangiogram11062 - Lower Extremity Venogram11063 - Lower Extremity Venography
Interventional Radiology Protocols
11101 - Carotid Angiography - Direct Stick Method11102 - Vertebral Angiography - Retrograde Brachial Artery Injection11103 - Selective Carotid or Vertebral Artery Studies - Retrograde Femoral Artery Approach11104 - Arch Aortogram11105 - Abdominal Aortogram - Seldinger Technique - Femoral Artery with Lower Extremity Run-Off11106 - Trans-Lumbar Aortogram11107 - Selective Cerebral Angiogram - Femoral Approach11108 - Selective Celiac or Superior Mesenteric Angiogram11109 - Selective Renal Angiogram11110 - Arthropathy of the Knee11111 - Shoulder Arthrogram11112 - Lung Biopsy11113 - Bronchoscopy - Biopsy11114 - Kidney Biopsy with Fluoroscopic or Ultrasound Control11115 - Renal Cyst Puncture11116 - Endoscopic Retrograde Cholangiopancreatography (ERCP)11117 - Placement of Indwelling Hepatic Artery Catheter11118 - Routine Nursing Orders - Indwelling Hepatic Artery Catheter11119 - Protocol for Hepatic Artery Catheter Obstruction
Nuclear Medicine Protocols
11201 - Bone Scintigraphy11202 - Brain Scintigraphy11203 - Dynamic (Brain Flow) Scintigraphy11204 - Cisternography11205 - First Pass Ejection Fraction11206 - Gallbladder Scintigraphy11207 - Gallium Scintigraphy11208 - Liver-Spleen Scintigraphy11209 - Lung Scintigraphy - Perfusion11210 - Lung Scintigraphy - Ventilation11211 - Left Ventriculography (MUGA)11212 - Myocardial Scintigraphy - 99mmTc Pyrophosphate11213 - Myocardial Scintigraphy - Thallium Stress and Redistribution11214 - Renal Scintigraphy11215 - Renography11216 - Schillings Procedure11217 - Thyroid Scintigraphy11218 - Chemicals and Drugs that Interfere with 24-Hour 123I Thyroid Uptake
Ultrasound Protocols
11301 - General Principles of Ultrasound Procedures11302 - Abdominal Ultrasonography - General Guidelines11303 - Breast Ultrasonography - General Guidelines11304 - Gynecological Ultrasonography - General Guidelines11305 - Lower Extremity Venous Duplex Evaluation (R/O Deep/Superficial Vein Thrombosis)11306 - Obstetrical Ultrasonography - General Guidelines11307 - Testicular Ultrasonography - General Guidelines11308 - Thyroid Ultrasonography - General Guidelines11309 - Transvaginal/Endovaginal Ultrasonography - General Guidelines11310 - Upper Extremity Vein Mapping for Placement of a Dialysis Access11311 - Urological Ultrasonography - General Guidelines