Recording of x-ray interpretation in patients' notes: urgent and emergency cases [QSI Ref: XR-514]

Hospital compliance with Ionising Radiation (Medical Exposure) Regulations 2000 (IRMER) regarding x-ray exposure and appropriately timed written evaluations.

IRMER states 'the employer shall ensure that a clinical evaluation of the outcome of each medical exposure is carried out and recorded [1]'. Therefore, each individual examination requires a written evaluation (report) recorded in the patient’s record at a time when the evaluation will influence the management of the patient. For many examinations, especially out of hours, this interpretation will be performed by the clinician because the management decision will be made before the definitive report from the radiology department is available. This audit focuses on those areas where the final radiology report is unlikely to be available when the management decision is made. The audit should be targeted at areas of work where this is likely to be the case e.g. A&E and Emergency Admissions Unit and should consider in-hours examinations separately from out-of-hours where it may be appropriate to wait for the radiology report for a non-urgent in-patient x-ray in-hours, but if the patient requires an urgent out-of-hours x-ray this implies the need for an urgent management decision. Also there may be less clinical support for trainee grade doctors out-of-hours.The Care Quality Commission wrote to all Acute Trust Chief Executives in July 2011 requiring them to audit the recording of radiological reports and to develop an improvement plan. The RCR 2016 publication of standards for the reporting of imaging investigations by non-radiologist medically qualified practitioners states that compliance with the standards outlined in the document should be audited as experience shows that if there is no record of the imaging interpretation, it may appear that the imaging investigation has not been viewed [2].

The standard: 

100% of urgent and emergency plain x-ray examinations will have a written evaluation (report) recorded in the notes by the clinician at a time when the evaluation will influence the management of the patient.

Target: 

100%

Indicators: 

Percentage of x-ray exposures with a written evaluation recorded in the patient notes at a time which will influence patient management.

Data items to be collected: 

• Patient x-ray exposures over a selected time period

• Correlation with patient notes for the selected exposures

Suggested number: 

Look at 5 examinations per day for a week (25 cases) in a number of different clinical settings.

1. Present audit findings to the relevant departments

2. Impress on the clinicians the need to record an x-ray interpretation in the notes when it is not timely to await the formal report

3. Emphasise to trainee doctors they are not expected to be expert reporters but need to spot gross abnormalities requiring urgent treatment

4. Repeat audit in 3-6 months to confirm compliance

• Access to PACS and HISS/RIS system

• Access to patient notes

• Radiologist (4-6 hours)

1. The Ionising Radiation (Medical Exposure) Regulations 2000.

2. Standards for the reporting of imaging investigations by non-radiologist medically qualified practitioners. BFCR (16) 5. https://www.rcr.ac.uk/system/files/publication/field_publication_files/bfcr165_non-radiologist_reporting.pdf [accessed 22 09 16]

Dr MAF McNeill and Dr L Cope. Updated by A-L Chang