Radiology Reporting by Other Doctors [QSI Ref: XR-514]

Effectiveness of arrangements to transfer the responsibility for the reporting of specified imaging examinations (involving the use of radiation) to referring clinicians.

The Ionising Radiation (Medical Exposure) Regulations 2017 stipulate that that The employer must take steps to ensure that a clinical evaluation of the outcome of each exposure, other than where the person subject to the exposure is a carer or a comforter, is recorded in accordance with the employer’s procedures including, where appropriate, factors relevant to patient dose. [1].  

All radiological examinations should be reported either by appropriately trained radiology department staff or by referring staff outwith the radiology department when responsibility for reporting specific categories of imaging examinations has been transferred by written agreement with the clinician(s) concerned and the approval of management. 

This audit is designed to determine whether such arrangements for delegation are being properly implemented.

The standard: 

All examinations where the responsibility for reporting has been transferred to the referrer as the result of a written agreement that a radiologist’s report is not required [1] should be formally reported by the referrer in the patient’s case notes. (Ideally on the PACS/RIS system if this is practical.)

Target: 

100%

Indicators: 

% of examinations for which responsibility for reporting has been transferred to the referrer and in which there is a written report.

Data items to be collected: 

For each examination, record whether or not a report has been written in the case notes of the patient or on the PACS/RIS system.

Suggested number: 

100 consecutive imaging examinations involving the use of radiation, (inpatients or outpatients) in which responsibility for reporting has been transferred to the referrer.

Discuss the results of the audit with the referrers and review the delegating agreement. 

If examinations are not being formally reported as agreed, then changes need to be made so as to achieve improved compliance with the agreement.

Improve the organization of clinical service and the training of referrers.

Consider increases in resources for radiology.

Computer records.

Review of case notes.

Data analysis by audit staff.

Radiologist: 2 hours.

1. Ionising Radiation (Medical Exposure) Regulations 2017 

2. Standards for the reporting of imaging investigations by non-radiologist medically qualified practitioners, London RCR 2016

Taken from Clinical Audit in Radiology 100+ recipes RCR 1996, updated by CRASC 2007, by R Greenhalgh