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vi

SAMPLE RADIOLOGY POLICIES AND PROCEDURES

TABLE OF CONTENTS Introduction ....................................................................................................................... ii Acknowledgements.......................................................................................................... iv Administration ................................................................................................................. 15

A-1. Department Overview.............................................................................................................. 16 A-2. Scope of Services.................................................................................................................... 16 A-3. Hours of Operation/Staffing ..................................................................................................... 17 A-4. Radiologists ............................................................................................................................. 17 A-5. Individual Department Plan ..................................................................................................... 17 A-6. Types of Service ...................................................................................................................... 19 A-7. Ages of Patients Served .......................................................................................................... 19 A-8. Goals 20 A-9. Requirements for Staff:............................................................................................................ 20 A-10. Care or Service Delivery Method....................................................................................... 24 A-11. Assignments ...................................................................................................................... 24 A-12. Staffing Plan ...................................................................................................................... 24 A-13. Verbal Orders .................................................................................................................... 27 A-14. Ordering Privileges ............................................................................................................ 27 A-15. Physician Orders ............................................................................................................... 28 A-16. Operation of Radiology Equipment.................................................................................... 29 A-17. Requesting Radiologic Exams........................................................................................... 30 A-18. Scheduling Outpatient Diagnostic Procedures .................................................................. 31 A-19. Scheduling of Needle Localizations Prior to Surgery......................................................... 32 A-20. Scheduling of Patients with Known Latex Allergy.............................................................. 32 A-21. Request/Order Changes and Errors and Corporate Compliance ...................................... 33 A-22. Canceled Procedure Charting and Corporate Compliance ............................................... 35 A-23. Processing Patients During Planned Computer Downtime ............................................... 35 A-24. Informed Consent .............................................................................................................. 36 A-25. Consent for Invasive Procedures or Conscious Sedation ................................................. 37 A-26 Consent to Treatment/ Informed Consent ......................................................................... 40 A-27. Guidelines for Radiology Usage in Other Areas ................................................................ 46

Interventional Radiology ................................................................................................ 49

IR-1. IR-2. IR-3. IR-4. IR-5. IR-6. IR-7. Patient Identification and Marking of Surgical Site ............................................................ 50 Discharge Planning Assessment ....................................................................................... 50 Discharge Guidelines Following Special Procedures Standard......................................... 52 Scope of Patient Assessment and Appropriateness of Invasive/Interventional Procedures Standard......................................................................................................... 53 Scope of Patient Assessment (Non-Medical Staff) Standard............................................. 54 History and Physicals (Requirements) Standard ............................................................... 55 Pre-Anesthesia/Conscious Sedation Assessment, Evaluation, and Planning................... 57

The policies and procedures in this document are all modeled closely on practices followed within the facilities that contributed them. In publishing them, AHRA intends only to provide a reference that may be useful to other facilities. AHRA does not in any sense endorse or recommend any of these policies or procedures. Individual facility managements bear complete responsibility for establishing their own rules and enforcing the implementation of these rules.

Introduction

vii

IR-8. Post-Procedure Status....................................................................................................... 59 IR-9. Scope of Reassessment.................................................................................................... 59 IR-10. Pre-, Intra-, Post-Procedure and Follow-Up (Interventional/Invasive, Sedation) Standard ............................................................................................................................ 60

Human Resources........................................................................................................... 64

HR-1. HR-2. HR-3. HR-4. HR-5. HR-6. HR-7. HR-8. HR-9. HR-10. HR-11. HR-12. HR-13. HR-14. HR-15. HR-16. HR-17. HR-18. HR-19. HR-20. HR-21. HR-22. HR-23. Certification Requirements--Technologists....................................................................... 65 Notification of Inability to Report for Duty .......................................................................... 65 Telephone Courtesy .......................................................................................................... 66 Clock-in/Clock-out Procedures .......................................................................................... 67 Overtime ............................................................................................................................ 68 X-Ray Room Care ............................................................................................................. 68 Evening Shift Technologists' Responsibilities/Duties ........................................................ 69 Night Shift Technologist Duties.......................................................................................... 70 Staff Meetings.................................................................................................................... 71 Tardiness and Fractional Overtime.................................................................................... 72 Emergency Call-Out for Sections with No Formal Call System ......................................... 73 Safety................................................................................................................................. 73 Employee Safety Responsibility ........................................................................................ 74 Internal Disaster................................................................................................................. 74 Incident Report Form ......................................................................................................... 77 Patient/Visitor Property Loss or Damage........................................................................... 77 Employee Incident Reporting............................................................................................. 77 Competency an Skill Verification Summary Sheet ............................................................ 79 Job Description Addendum-Age Specific Criteria.............................................................. 80 Confidentiality Statement................................................................................................... 81 Diagnostic X-Ray Department Orientation........................................................................ 82 Age & Skill Competency Verification Sheet ....................................................................... 83 Venipuncture Policy ........................................................................................................... 84

Equipment ....................................................................................................................... 87

E-1. Equipment Management Plans ............................................................................................... 88 E-2. Preventive MaintenancE.......................................................................................................... 92 E-3. Electrical Safety....................................................................................................................... 94 E-4. Quality Control......................................................................................................................... 95 E-5. Medical Device Reporting........................................................................................................ 96 E-6. (Alternative or supplement to E-5) Reporting Adverse Medical Device Incidents ................... 98 E-7. Expected Reporting Data Elements ...................................................................................... 100 E-8. Radiology Engineering Rounds Routine................................................................................ 102 E-9. Imaging Equipment Purchase Evaluations ............................................................................ 103 E-10. Imaging Equipment Incoming Inspection......................................................................... 103 E-11. Imaging Equipment Orientation, In-Service Training, and Competency Assessment ..... 104

The policies and procedures in this document are all modeled closely on practices followed within the facilities that contributed them. In publishing them, AHRA intends only to provide a reference that may be useful to other facilities. AHRA does not in any sense endorse or recommend any of these policies or procedures. Individual facility managements bear complete responsibility for establishing their own rules and enforcing the implementation of these rules.

viii SAMPLE RADIOLOGY POLICIES AND PROCEDURES

E-12. E-13. E-14. E-15. E-16. E-17 E-18 E-19 E-20. FFM-1. FFM-2. FFM-3. FFM-4. FFM-5. FFM-6. GS-1. GS-1. GS-2. GS-3. GS-4. GS-5. GS-6. GS-7. GS-8. GS-9. GS-10. GS-11. GS-12. GS-13. GS-14. GS-15. GS-16. GS-17. GS-18. GS-19. GS-20. GS-21. GS-22. Equipment Lock-Out, Tag-Out......................................................................................... 104 Monitoring Imaging Patient Care Equipment Vendors..................................................... 105 Parts Requisition System................................................................................................. 105 Product/Device Hazard Recalls ....................................................................................... 106 Imaging Patient Care Equipment Repair/Replacement ................................................... 107 Radiological Engineering Safety...................................................................................... 108 Radiological Engineering Corrective Work Order System ............................................... 111 Technical Literature ......................................................................................................... 111 Silver Reclamation........................................................................................................... 112 Film Availability ................................................................................................................ 114 Film Copies...................................................................................................................... 114 Film Storage .................................................................................................................... 115 Report Turnaround Time ................................................................................................. 115 Report for Incomplete Exam ............................................................................................ 116 Films and Record Ownership and Patient Access........................................................... 117 (Option A) General Safety ............................................................................................... 119 (Option B) General Safety ............................................................................................... 120 Safety Inspection Check List ........................................................................................... 124 Patient Handling/Care of the Back................................................................................... 126 Electrical Hazard Prevention ........................................................................................... 128 Evacuation Procedures.................................................................................................... 129 Equipment Safety ............................................................................................................ 129 Mechanical Safety ........................................................................................................... 130 Environmental Management/Safety Plan ........................................................................ 131 Procedure for Response to a Fire.................................................................................... 143 Fire and Explosion ........................................................................................................... 143 Tornado Alert and Warning.............................................................................................. 144 Bomb Threat .................................................................................................................... 145 Suspected Bomb Discovery............................................................................................. 145 Internal Disaster............................................................................................................... 145 Incident Report Form ....................................................................................................... 150 Employee Incident Reporting........................................................................................... 150 Inpatient Incident ............................................................................................................. 151 Outpatient or Visitor Incident ........................................................................................... 151 Patient/Visitor Property Loss or Damage......................................................................... 151 Violent Situation Alert ...................................................................................................... 152 Workplace Violence Prevention Plan............................................................................... 152 Employee Contact with Hazardous Materials .................................................................. 155

Film File Management................................................................................................... 113

EC ­ General Safety ...................................................................................................... 118

The policies and procedures in this document are all modeled closely on practices followed within the facilities that contributed them. In publishing them, AHRA intends only to provide a reference that may be useful to other facilities. AHRA does not in any sense endorse or recommend any of these policies or procedures. Individual facility managements bear complete responsibility for establishing their own rules and enforcing the implementation of these rules.

Introduction

ix

GS-23. GS-24. GS-25. GS-26. IC-1. IC-2. IC-3. IC-4. IC-5. IC-6. IC-7. IC-8. IC-9. IC-10. IC-11. IC-12. IC-13. IC-14. IC-15 PC-1. PC-2. PC-3. PC-4. PC-5. PC-6. PC-7. PC-8. PC-9. PC-10. PC-11. PC-12. PC-13. PC-14. PC-15. PC-16. PC-17. PC-18.

Handling and Disposal of Hazardous Materials............................................................... 156 Hazardous Material Program........................................................................................... 157 Employee Safety Responsibility ...................................................................................... 158 Sentinel Event.................................................................................................................. 159 General Policy Statements .............................................................................................. 167 Environmental Considerations......................................................................................... 171 Supplies and Accessories................................................................................................ 173 Traffic Control FOR IMAGING PROCEDURES............................................................... 174 Portable Equipment-- DISINFECTANT CLEANING ........................................................ 175 Standard Infection Control Precautions Policies.............................................................. 175 Personnel Responsibilities............................................................................................... 176 Personal Protective Equipment: Gloves, Gowns, Masks, and Eye Protection ................ 177 Bio Hazardous Materials: Needles and Other Sharps ..................................................... 178 Isolation Attire .................................................................................................................. 178 Portable Exams for Patients requiring contact, DROPLET or airborne precautions........ 181 STANDARD Precautions: Soiled/Used Linens ................................................................ 182 Waste Management Precautions: Waste Disposal.......................................................... 183 Disposal of Body Waste................................................................................................... 184 Ultrasound "Endo" Transducer Disinfection Process "CIDEX OPA" ................................ 184 Preps for Special Radiologic Procedures ........................................................................ 187 Pediatric Preps for Diagnostic Procedures ...................................................................... 188 Preps for Diagnostic Procedures on Adolescents over Age 12 and Adults ..................... 191 Patient Information and Preparations .............................................................................. 195 Prep Procedure for CT Scans.......................................................................................... 198 Appropriateness Indications Disclaimer........................................................................... 199 Clinical Indications for Exam............................................................................................ 200 Scheduling Guidelines for Outpatient Diagnostic Procedures ......................................... 223 Exam Appropriateness and Screening ............................................................................ 224 Requirements from Emergency Department for Urgent Pelvic Ultrasound ..................... 225 General Policies Regarding privacy, Contrast Media and spling removal for Patient Care.................................................................................................. 225 Patient Responsibilities.................................................................................................... 226 Patient Rights .................................................................................................................. 226 Patient Rights to Personal and Informational Privacy and Confidentiality ....................... 227 Patient Rights to Consent/Refusal for Treatment ............................................................ 228 Care/Handling for Suspected Spinal Fracture Patients ................................................... 228 Patient Safety .................................................................................................................. 229 Transportation--Requisition Information ......................................................................... 230

EC ­ Infection Control................................................................................................... 166

EC--Patient Care........................................................................................................... 185

The policies and procedures in this document are all modeled closely on practices followed within the facilities that contributed them. In publishing them, AHRA intends only to provide a reference that may be useful to other facilities. AHRA does not in any sense endorse or recommend any of these policies or procedures. Individual facility managements bear complete responsibility for establishing their own rules and enforcing the implementation of these rules.

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SAMPLE RADIOLOGY POLICIES AND PROCEDURES

PC-19. PC-20. PC-21. PC-22. PC-23. PC-24. PC-25. PC-26. PC-27. PC-28. PC-29. PC-30. PC-31. PC-32. PC-33. PC-34. PC-35. PC-36. PC-37. PC-38. PC-39. PC-40. PC-41. PC-42. PC-43. PC-44. PC-45. PC-46. PC-47. PC-48. PC-49. PC-50. PC-51. PC-52. PC-53. PC-54. PC-55. PC-56.

Transportation Information and Procedure--General...................................................... 231 Transportation Policy--Mode of Transport ...................................................................... 231 Transportation­Sign Out Procedure ................................................................................ 232 Transportation of Patients with IV's ................................................................................. 232 Transportation Policy--Psychiatric Patients .................................................................... 233 Transportation Policy--Infants......................................................................................... 234 Transportation Policy--Isolation Patients ........................................................................ 234 Transportation of Critically Ill Patient ............................................................................... 235 Critical Care Transport..................................................................................................... 236 Care and Handling of Critically Ill Patients....................................................................... 237 Use of/Changing IV Solutions.......................................................................................... 238 Medications in Radiology................................................................................................. 239 Contrast Reaction Policy ................................................................................................. 239 IV Contrast Administration Procedure ............................................................................. 239 Treatment of Reaction to Contrast Media........................................................................ 244 (CPR # 1) Cardiac/Respiratory Arrest ............................................................................. 244 (CPR #2) Code 99/Cardiopulmonary Resuscitation ........................................................ 245 Nursing Observation Area--Radiology............................................................................ 248 Employees' Responsibility Regarding Latex Sensitivity .................................................. 249 Alert Systems for Latex Sensitive Patients ...................................................................... 250 Products to be Used for Latex Sensitive Patients............................................................ 250 Room Preparation for Latex Sensitive Patients ............................................................... 251 Contents of Latex Sensitivity Kit and Location................................................................. 252 Pregnancy Determination for Patients Prior to X-Ray, Sedation, or Magnetic Exposure .......................................................................................................... 252 Urinary Catheterization .................................................................................................... 253 Conscious Sedation......................................................................................................... 254 Adverse Drug Reaction Reporting ................................................................................... 263 Medication Errors............................................................................................................. 263 Iodinated Contrast Agent Selection ................................................................................. 264 MRI Safety/Screening...................................................................................................... 265 Ostomy Pouching ............................................................................................................ 266 Suctioning, Oropharyngeal and Nasopharyngeal ............................................................ 267 Pulse Oximetry ................................................................................................................ 268 Emergency Surgery or Death of the Therapeutic Radioactive Patient (Implants and unsealed sources) ........................................................................................................... 270 Radiation Safety for Patients Receiving Therapeutic Radioactive Materials ................... 272 Advance Directives .......................................................................................................... 277 Patient Rights to Care and Comfort................................................................................. 280 Patient Rights and Responsibilities ................................................................................. 280

The policies and procedures in this document are all modeled closely on practices followed within the facilities that contributed them. In publishing them, AHRA intends only to provide a reference that may be useful to other facilities. AHRA does not in any sense endorse or recommend any of these policies or procedures. Individual facility managements bear complete responsibility for establishing their own rules and enforcing the implementation of these rules.

Introduction

xi

PC-57. Patients with History of Allergies or Contraindications .................................................... 284

Radiation Safety ............................................................................................................ 275

RS-1. RS-2. RS-3. RS-4. RS-5. RS-6: RS-6a. RS-7. RS-8. RS-9. RS-10. RS-11. RS-12. RS-13. RS-14. RS-15. NM-1. NM-2. NM-3. NM-4. NM-5. NM-6. NM-7. NM-8. NM-9. NM-10. NM-11. NM-12. NM-13. NM-14. NM-15. NM-16. RR-1. RR-2. RR-3. Radiation/Fluoroscopy Safety.......................................................................................... 287 Noninterpretive Fluoroscopy............................................................................................ 293 Prenatal Radiation Exposure ........................................................................................... 293 Instructions Concerning Pregnant Employees................................................................. 296 Radiation Safety Committee ............................................................................................ 305 Medical Radiation Physicist Responsibilities (Option 1) .................................................. 306 Medical Radiation Physicist Responsibilities (Option 2) .................................................. 307 ALARA Program .............................................................................................................. 309 General Rules of Radiation Safety .................................................................................. 314 Radiation Protection to Patient Holders--State Regulations........................................... 315 Repeat Exams ................................................................................................................. 316 Persons Permitted in X-ray Rooms ................................................................................. 317 Radiation Safety Rules for Portable Radiography ........................................................... 318 Radiation Safety Rules for Surgical Orthopedic Radiography ......................................... 318 Emergency Surgery or Death of the Therapeutic Radioactive Patient ............................ 318 Patients Receiving Therapeutic Radioactive Materials.................................................... 321 Nuclear Medicine Equipment Quality Control Schedule .................................................. 326 Survey Instrument Calibration ......................................................................................... 329 Receiving and Opening Packages Containing Radioactive Material............................... 331 Radioactive Waste Management..................................................................................... 332 Written Directive for Radiopharmaceuticals..................................................................... 334 Procurement, Storage, Distribution, and Preparation of Radiopharmaceuticals ............. 335 Medication Dose System for Radiopharmaceuticals ....................................................... 337 Administration of Radiopharmaceuticals in Nuclear Medicine......................................... 338 Wipe Tests and Area Surveys ......................................................................................... 340 Handling of Radioactive Sealed Sources ........................................................................ 340 Special Handling for Patients Administered Radioactive Materials ................................. 341 Radiation Safety Checklist for Iodine Therapy Over 30 mCi ........................................... 346 I Therapy Room Survey Report ....................................................................................... 348 Administration of Radioactive Iodine Dose > 30 mCi....................................................... 349 Record for the Administration of Radioiodine > 30 mCi................................................... 350 131-I Thyroid Therapy Checklist...................................................................................... 351 General Guidelines .......................................................................................................... 353 Addenda/Corrected Reports ............................................................................................ 353 Facsimile (FAX) Transmission of Patient Health Information .......................................... 353

Nuclear Medicine........................................................................................................... 326

Results Reporting ......................................................................................................... 352

The policies and procedures in this document are all modeled closely on practices followed within the facilities that contributed them. In publishing them, AHRA intends only to provide a reference that may be useful to other facilities. AHRA does not in any sense endorse or recommend any of these policies or procedures. Individual facility managements bear complete responsibility for establishing their own rules and enforcing the implementation of these rules.

xii

SAMPLE RADIOLOGY POLICIES AND PROCEDURES

Cardiac Catheterization ................................................................................................ 358

CC-1. CC-2. CC-3. CC-4. CC-5. CC-6. CC-7. CC-8. CC-9. CC-10. CC-11. CC-12. CC-13. CC-14. CC-15. CC-16. CC-17. CC-18. CC-19. CC-20. CC-21. CC-22. CC-23. CC-24. CC-25. CC-26. CC-27. CC-28. CC-29. CC-30. CC-31. CC-32. CC-33. CC-34. CC-35. CC-36. CC-37. CC-38. CC-39. Department Goals............................................................................................................ 360 Mission Statement ........................................................................................................... 360 Performance Improvement .............................................................................................. 360 Philosophy ....................................................................................................................... 360 Population Served ........................................................................................................... 361 Reference Materials......................................................................................................... 361 Scope of Services............................................................................................................ 362 Staffing Plan .................................................................................................................... 363 Standards and Practice Guidelines ................................................................................. 363 Accreditation Process ...................................................................................................... 363 Lab Procedures ............................................................................................................... 363 Loaning/Borrowing Supplies ............................................................................................ 365 Disaster Call List.............................................................................................................. 365 Heart Diagram ................................................................................................................. 366 Infection Control............................................................................................................... 366 Ordering Supplies ............................................................................................................ 367 Patient Monitoring for Intravenous Analgesia .................................................................. 368 Pre-procedure Requirements .......................................................................................... 370 Pre- and Post-procedure Patient Instructions.................................................................. 372 Preparation of the Cath Lab............................................................................................. 373 Safety Guidelines............................................................................................................. 373 Sterile Scrubbing, Gowning, and Gloving ........................................................................ 375 Surgical Standby for PTCA.............................................................................................. 377 Charge Record ................................................................................................................ 377 Chart Documentation Requirements ............................................................................... 378 Equipment Cleaning ........................................................................................................ 379 Admission Procedure....................................................................................................... 380 Post-procedure Observation............................................................................................ 381 Pressure Dressing ........................................................................................................... 382 Pulse Oximetry ................................................................................................................ 382 Securing Arterial and Venous Sheaths............................................................................ 383 Swan-Ganz Monitoring .................................................................................................... 386 Invasive Catheter Removal.............................................................................................. 389 Manual Pressure for Hemostasis..................................................................................... 390 Anesthesia ....................................................................................................................... 390 Scheduling Cases in the Lab ........................................................................................... 392 Delaying Procedures in the Cath Lab .............................................................................. 394 Staff Licensing ................................................................................................................. 395 Staff Responsibilities ....................................................................................................... 396

The policies and procedures in this document are all modeled closely on practices followed within the facilities that contributed them. In publishing them, AHRA intends only to provide a reference that may be useful to other facilities. AHRA does not in any sense endorse or recommend any of these policies or procedures. Individual facility managements bear complete responsibility for establishing their own rules and enforcing the implementation of these rules.

Introduction

xiii

CC-40. CC-41. CC-42. CC-43. CC-44.

Employee Orientation ...................................................................................................... 398 Equipment Orientation ..................................................................................................... 399 New Employees............................................................................................................... 400 Rules of Conduct ............................................................................................................. 403 Code Blue Duties............................................................................................................. 403

Magnetic Resonance Imaging ...................................................................................... 405

MRI­1. Restricted Magnetic Field Area Defined .......................................................................... 406 MRI­2. Caution in Handling Objects Near Magnetic Field ........................................................... 406 MRI­3. Claustrophobia and Sedation .......................................................................................... 406 MRI­4. Patient Pregnancy ........................................................................................................... 407 MRI­5. Fetal MRI Examination .................................................................................................... 407 MRI­6. Personnel and Visitor Screening ..................................................................................... 407 MRI­7. Response to Respiratory or Cardiac Arrest in the Magnet Room.................................... 407 MRI­8. Response to a Fire .......................................................................................................... 408 MRI­9. Safe Handling of Liquid Helium and Liquid Nitrogen ....................................................... 409 MRI­10. Precautions for Emergency Equipment .................................................................... 409 MRI­11. Electrical Safety........................................................................................................ 410 MRI­12. Magnet Safety .......................................................................................................... 410 MRI­13. Cryogen Safety......................................................................................................... 411 MRI­14. Preventive Maintenance of MRI Scanner................................................................. 411 MRI­15. Housekeeping .......................................................................................................... 411 MRI­16. Precautions to be Enforced by PolicE or Security Personnel................................... 412 MRI­17. Employee Pregnancy ............................................................................................... 412 MRI­18. Hazard/Warning Communication ............................................................................. 413 MRI­19. Procedure for Response to Low Oxygen Alarm ....................................................... 413 MRI­20. Magnet Quench........................................................................................................ 413 MRI­21. Removal of Magnetic Field....................................................................................... 414 MRI­22. Restarting the Superconductive Magnet .................................................................. 414 MRI­23. Scanning Protocols .................................................................................................. 414 MRI­24. Call Policy for Emergency Scans ............................................................................. 414 MRI­25. Patient Information and Preparations....................................................................... 416 MRI­26. Patient Screening ..................................................................................................... 418 MRI­27. Patient Questionnaire............................................................................................... 418 MRI­28. Outside Referrals ..................................................................................................... 423 MRI­29. Devices Safely Scanned with MRI 1.5 Tesla............................................................ 424 MRI­30. Contraindications to MRI Scanning .......................................................................... 425 MRI­31. Warning of MRI Scanning and Effects ..................................................................... 426

Mammography............................................................................................................... 428

M-1. M-2. Mammography Lead Interpreting Physicians' Responsibilities........................................ 429 Interpreting Physicians' Qualifications ............................................................................. 430

The policies and procedures in this document are all modeled closely on practices followed within the facilities that contributed them. In publishing them, AHRA intends only to provide a reference that may be useful to other facilities. AHRA does not in any sense endorse or recommend any of these policies or procedures. Individual facility managements bear complete responsibility for establishing their own rules and enforcing the implementation of these rules.

xiv SAMPLE RADIOLOGY POLICIES AND PROCEDURES

M-3. Technologists' Qualification Requirements...................................................................... 430 M-4. Mammography Technologists' Orientation ...................................................................... 431 M-5. Technologists' Performance Requirements..................................................................... 431 M-6. Technologists' Restrictions .............................................................................................. 432 M-7. Physicists' Qualifications ................................................................................................. 433 M-8. Physicists' Responsibilities .............................................................................................. 434 M-9. Personnel Records Retention.......................................................................................... 434 M-10. Mammography Services .................................................................................................. 434 M-11. Patient Selection Criteria ................................................................................................ 435 M-12. Scheduling Mammography Patients ................................................................................ 435 M-13. Comparison of Previous Films......................................................................................... 436 M-14. Exam Preparation ............................................................................................................ 436 M-15. Screening Mammography Standing Orders .................................................................... 437 M-16. Diagnostic Mammography ............................................................................................... 438 M-17. Breast Implant Imaging.................................................................................................... 438 M-18. Mammographic Image Identification................................................................................ 438 M-19. Repeat Film ..................................................................................................................... 439 M-20. Mammography Patients' Notification of Results .............................................................. 439 M-21. Follow-up for Abnormal Mammography Results.............................................................. 440 M-22. Self-Referred Patients ..................................................................................................... 441 M-23. Mammography Tracking .................................................................................................. 441 M-24. Mammography Film Retention and Release ................................................................... 441 M-25. Mammography Quality Assurance Program.................................................................... 442 M-26. Mammography Assurance Responsibility........................................................................ 442 M-27. Equipment Quality Control............................................................................................... 443 M-28. Quality Ccontrol Test Results .......................................................................................... 444 M-29. Department Cleanliness .................................................................................................. 444 M-30. Infection Control............................................................................................................... 445 M-31. Quality Assurance Records ............................................................................................. 446 M-32. Patient Complaints........................................................................................................... 446 M-33. Mammography Medical Outcomes Audit......................................................................... 447 M-34. Mobile Mammography Services ...................................................................................... 448 Websites 449

The policies and procedures in this document are all modeled closely on practices followed within the facilities that contributed them. In publishing them, AHRA intends only to provide a reference that may be useful to other facilities. AHRA does not in any sense endorse or recommend any of these policies or procedures. Individual facility managements bear complete responsibility for establishing their own rules and enforcing the implementation of these rules.

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