Clinical Guideline for the Reporting of Clinical Imaging Examination ...

CLINICAL GUIDELINE FOR THE REPORTING OF CLINICALIMAGING EXAMINATIONS AND PROCEDURES1.0 Aim & PurposeThis document is applicable to the reporting of imaging and procedures undertaken by theClinical Imaging Team. It is inclusive of formal reporting and red dot reporting but excludesobstetric reporting as part of the NHS Foetal Anomaly Screening Programme. Thepurpose of the document is to clarify the level of image interpretation and the staff groupsinvolved. The document also provides guidance on the structure and content of reporting.2.0 The Guidance2.1 ResponsibilitiesAccording to documentation from the Royal College of Radiologists (2012):It is the responsibility of the reporting practitioner to ensure that the reports aretimely, clear and precise; to clearly document advice on further management oraction, where appropriate; and ensure the urgency for action is documentedwithin the content of the report.It is the responsibility of the referrer/referring team to read and act upon theresult of every investigation it generates2.2 DefinitionsReporting: Reporting describes the provision of a clinical opinion throughconsideration of the medical history, presenting signs and symptoms declared by thereferrer, the appropriateness/ limitations of the imaging method, and observation anddescription of normal and abnormal findings to enable the referring practitioner tomake 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 possibleUrgent Findings: Where medical evaluation is required within 24 hoursClinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresPage 1 of 11

Significant Unexpected Findings: Where the reporting practitioner has concernsthat the findings are significant for the patient and may be unexpected by the referrer.2.3 Staff Groups2.3.1 Reporting PractitionersConsultant RadiologistsSpecialist RegistrarsConsultant GI Radiographer acting within approved scope of practice (CI.IR.04& CI.IR.01)Consultant Breast Imaging Radiographer acting within approved scope ofpractice (CI.MER.01)Sonographers acting in accordance with local protocols (CI.US)Advanced Practitioners (Reporting Radiographers) in plain film reporting actingwithin 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 ReportsA report is an assessment of the examination/procedure and may also include adviceregarding patient management. According to the Royal College of Radiologists(2006) the usual format of reports will include:Clinical detailsA description of the findingsA conclusion or interpretation of findings in the clinical contextFor long or complex reports there should be a conclusion at the end of thereport which answers the clinical question in the request2.4.1 Quality, Accuracy and Verification of ReportsEach reporting practitioner is responsible for the quality and accuracy of their work.Reports are generated using voice recognition (VR) or typed directly onto theComputer Radiology Information System (CRIS). It is the responsibility of thepractitioner to check accuracy and readability before verifying the report. The reportis then released to CRIS, InSight PACS (including InSight Web), MAXIMS and thepatient’s GP practice.Clinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresPage 2 of 11

Consultant Radiologists are viewed as the experts and all practitioners must refer tothem where any doubt exists and a second opinion is needed. Non-medical reportersreceive specific, specialist training to prepare them for the role. As part of thisassessment a Consultant Radiologist verifies reports during both training and asupervised period following qualification. A Consultant Radiologist has the authorityto 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 ofevery investigation they generate (RCR, 2012 & NPSA 2007).It is the responsibility of the Reporter to ensure that the referring Clinician, or anotherappropriate member of the clinical team is contacted if they consider that there is adanger of unexpected relevant information contained in the report not being actedupon (RCR, 2012).All reports are constructed on CRIS and once verified, are automaticallycommunicated to the referrer electronically, via the InSight Web, Clinical Care andMaxims systems; electronic reports are also sent to GPs via the GP link. Papercopies (known as white copies) are currently sent to Consultants, Wards and theEmergency Department; however this practice is reducing due to electronic systems.For reports which contain Critical, Urgent, or Unexpected Significant findings, thefollowing additional Safety Net procedures should be followed.2.5.1 Critical FindingsFor immediately life-threatening conditions (e.g. life-threatening intracranialhaemorrhage, tension pneumothorax), where emergency action is required as soonas possible, the referring clinician or an appropriate member of their team should benotified directly by telephone or in person.2.5.2 Urgent FindingsFor true on call/emergency cases the referring doctor has a responsibility to pursueand review the result, given that by definition the patient’s acute management will bedetermined 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, inthe clinical judgement of the reporter, there is a concern that the report will not beviewed in a timely manner (e.g. incidental pulmonary embolus discovered on anClinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresPage 3 of 11

inpatient CT before a weekend, or on an outpatient referral) the reporter or delegateddeputy should notify the referrer/referring team of the report.2.5.3 Unexpected Significant FindingsFor unexpected findings which do not require an urgent change in management butwhich are very important for the future care of the patient. (e.g. incidental lung canceron CXR performed for an unrelated indication), it is the responsibility of the reportingpractitioner or their nominated deputy to bring the report to the referrer/referringteam’s attention if, in their clinical judgement, there is a danger that the report will notbe viewed in a timely manner. The reporter may recommend the next actionsfollowing such a finding (i.e. in this example referral to a chest physician) but mustnot take responsibility for such referrals or the ordering of further examinations; theaccountability lies with the team managing the patient’s care.The communication of unexpected significant results may be delegated to a memberof the Clinical Imaging Administration Team at the judgement of the reporter.For all MIU referrals with unexpected significant findings, the reporting clinicianshould 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 oftheir team by the reporter, the telephoned result should be recorded on the report asan addendum, giving the date, time, name and role of the person who received thereport.Where communication of results is delegated to the Clinical Imaging AdministrationTeam, the report should be placed in the ‘Admin Action’ folder on InSight Web, alongwith a brief description of the action required. The Administration Team log thefollowing details from these actions in an Excel database:Patient nameCR numberProcedureReporterGP/Consultant’s Team/Wardcontact detailsClinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresPage 4 of 11Date & time of communicationPA who made the telephonecallAny additional commentsA note of the telephone communication is also made in the comments box on thepatient’s CRIS record.

2.5.5 Communicating Findings Directly with the PatientThe communication of results with the patient must be sensitive and honest. Resultsshould only be discussed if the images have been fully reviewed and the individualfeels competent and it is appropriate to inform the patient including answering anyquestions regarding ongoing care/management.2.6 Reporting Images of the DeceasedDeceased 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 reportedplease contact the x-ray dept.'The department will review images by request.2.7 Images Which Do Not Receive Clinical Evaluation by theImaging DepartmentIt is a statutory requirement of IR(ME)R that all examinations involving ionisingradiation are evaluated in the clinical record, either in the form of a report by aRadiologist or an opinion by another clinician.2.7.1 Reporting Arrangements in Other SpecialitiesBy agreement with the relevant clinical specialities the following examinations will notbe routinely reported by the clinical imaging department and the clinician's evaluationof the examination will be documented in the patient's clinical record:1) Non-paediatric orthopaedic plain radiographs from Orthopaedic wards, theatresand outpatient clinics including fracture clinic. EXCEPTIONS: chest and abdominalradiographs, requests from Physiotherapist and other non-medical practitioners.2) Orthodontic examinations (OPG and occlusal views) requested by the orthodonticdepartmentThe referring team can specifically request a radiologist report on any examination. Ifthis is made at the time of request the examination should be allocated to REFHOT.Clinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresPage 5 of 11

2.7.2 Pre- MRI Intra-Orbital Foreign Body ImagesFor radiographs to exclude the presence of foreign bodies within the eye which mayprohibit the patient from undergoing an MRI scan, MRI practitioners who have beendeemed competent will provide a report related to the presence of foreign body only.Further reporting is available by request.2.8 Location and Storage2.8.1 ReportsAll 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 ofNHS Foetal Anomaly Screening.2.9 ReferencesNational Patient Safety Agency (2007) Safer Practice Notice 16: EarlyIdentification 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 andInterpretation of Imaging Investigations. London: RCR.Accessed at:http://www.rcr.ac.uk/docs/radiology/pdf/StandardsforReportingandInetrpwebvers.pdfRoyal College of Radiologists (2012) Standards for the Communication of Critical,Urgent and Unexpected Significant Radiological Findings (2 nd Edition). London:RCR.Accessed at: http://www.rcr.ac.uk/docs/radiology/pdf/BFCR(12)11_urgent.pdfRoyal College of Radiologists (2011) Standards and Recommendations for theReporting and Interpretation of Imaging Investigations by Non-RadiologistMedically Qualified Practitioners and Teleradiologists. (2 nd Edition) London:RCR.Accessed at: http://www.rcr.ac.uk/docs/radiology/pdf/BFCR(11)2_Reporting.pdfClinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresPage 6 of 11

3.0 Monitoring compliance and effectivenessElement to beReporting standardsmonitoredLeadToolFrequencyReportingarrangementsActing onrecommendationsand Lead(s)Change inpractice andlessons to besharedDr P. CookAudit of reporting accuracy within imaging & audit of documentedevaluation by departments outside of imaging.AnnualReport to clinical imaging audit meetingThe lead will act on urgent findings immediately, any discussions/recommendation will be documented through the minutes of theclinical imaging audit meeting.Actions will be taken by the Lead, changes in practice will bereflected within this document. Lessons learned will be shared andimplemented through the clinical imaging audit meeting.4.0 Equality and DiversityThis document complies with the Royal Cornwall Hospitals NHS Trust service Equality andDiversity statement.4.1Equality Impact AssessmentThe Initial Equality Impact Assessment Screening Form is at Appendix 2.Clinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresPage 7 of 11

Appendix 1. Governance InformationDocument TitleClinical Guideline for the Reporting ofClinical Imaging Examination andProceduresCI.GEN.19Date Issued/Approved: 30 September 2013Date Valid From: 30 September 2013Date Valid To: 1 st September 2016Directorate / Department responsible(author/owner):Dr P. Cook, Speciality Lead, ClinicalImagingContact details: 01872 252285Brief summary of contentsThis guideline relates to the content anddelivery of reporting of radiographicimages or procedures undertaken by theclinical imaging team.Suggested Keywords:Target AudienceExecutive Director responsible forPolicy:X-ray, reporting, radiologists, imagingRCHT PCT CFTMedical DirectorDate revised: June 2016This document replaces (exact title ofprevious version):Approval route (names ofcommittees)/consultation:Clinical Guideline for the Reporting ofClinical Imaging Examination andProceduresClinical Imaging Clinical GovernanceDivisional Manager confirmingapproval processesName and Post Title of additionalsignatoriesSignature of Executive Director givingapprovalPublication Location (refer to Policyon Policies – Approvals andRatification):Document Library Folder/Sub FolderLinks to key external standardsBruce Daniel, Divisional ManagerEmma Spouse, Diagnostics Lead{Original Copy Signed}Internet & IntranetClinical / Clinical Imaging Intranet OnlyIonising Radiation (Medical Exposure)RegulationsClinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresPage 8 of 11

Related Documents:Training Need Identified?RCHT Radiation Safety PolicyNoVersion Control TableDateVersionNoSummary of ChangesNov 11 V1.0 Initial Issue18/6/2013 V2.027/8/2013 V3.0Updated to reflect changes in imaging PACSsystemUpdated document to include reportsexcluded from the document.Changes Made by(Name and Job Title)Naomi BurdenGovernanceRadiographerNaomi BurdenGovernanceRadiographerNaomi BurdenGovernanceRadiographerAll or part of this document can be released under the Freedom of InformationAct 2000This document is to be retained for 10 years from the date of expiry.This document is only valid on the day of printingControlled DocumentThis document has been created following the Royal Cornwall Hospitals NHS TrustPolicy on Document Production. It should not be altered in any way without theexpress permission of the author or their Line Manager.Clinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresPage 9 of 11

Appendix 2.Initial Equality Impact Assessment ScreeningFormClinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresCI.GEN.19Directorate and service area:Is this a new or existing Procedure?Clinical ImagingExistingName of individual completingTelephone:assessment: Naomi Burden018722550861. Policy Aim* To clarify reporting processes for imaging examinations andprocedures.2. Policy Objectives* To ensure the reporter fully understands their responsibilitieswhen requesting medical imaging.3. Policy – intendedOutcomes*2 How will you measurethe outcome?• Clear standards in placeo Local document which reflects the requirements of thelaw in relation to ionising radiationThrough audit and monitoring5. Who is intended tobenefit from the Policy?6a. Is consultationrequired with theworkforce, equalitygroups, local interestgroups etc. around thispolicy?Staff and patientsNob. If yes, have thesegroups been consulted?c. Please list any groupswho have been consultedabout this procedure.*Please see Glossary7. The ImpactPlease complete the following table.Are there concerns that the policy could have differential impact on:Equality Strands: Yes No Rationale for Assessment / Existing EvidenceAge x There is no impact on this groupSex (male, female, transgender/ genderreassignment)Race / Ethniccommunities /groupsxxThere is no impact on this groupThere is no impact on this groupClinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresPage 10 of 11

Disability -learningdisability, physicaldisability, sensoryimpairment andmental healthproblemsReligion /other beliefsMarriage and civilpartnershipxxxThere is no impact on this groupThere is no impact on this groupThere is no impact on this groupPregnancy and maternity x There is no impact on this groupSexual Orientation,x There is no impact on this groupBisexual, Gay, heterosexual,LesbianYou will need to continue to a full Equality Impact Assessment if the following have beenhighlighted:You have ticked “Yes” in any column above andNo consultation or evidence of there being consultation- this excludes any policieswhich have been identified as not requiring consultation. orMajor service redesign or development8. Please indicate if a full equality analysis is recommended. Yes No9. If you are not recommending a Full Impact assessment please explain why.Signature of policy developer / lead manager / directorDate of completion and submissionNames and signatures ofmembers carrying out theScreening Assessment1.2.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 3HDA summary of the results will be published on the Trust’s web site.Signed _______________Date ________________Clinical Guideline for the Reporting of Clinical Imaging Examination and ProceduresPage 11 of 11