Standard Operating Procedure: Radiology Department Clinical Operations

This Standard Operating Procedure (SOP) outlines the mandatory clinical and administrative workflows for the Radiology Department. The objective of this document is to ensure patient safety, maintain diagnostic image quality, optimize workflow efficiency, and guarantee strict adherence to ALARA (As Low As Reasonably Achievable) radiation safety principles. This protocol applies to all radiologists, radiologic technologists, nursing staff, and administrative personnel.

Section 1: Patient Identification and Pre-Examination Screening

• Verify patient identity using two unique identifiers (full name and Date of Birth) against the Electronic Health Record (EHR) and the radiology requisition order.
• Confirm the correct examination site and procedure against the physician’s order.
• Perform a thorough pregnancy screening for all patients of childbearing age (12–55) prior to any ionizing radiation procedure.
• Screen for contraindications, including metal implants, pacemakers, or contrast media allergies.
• Obtain and verify informed consent for invasive or contrast-enhanced procedures.

Section 2: Clinical Workflow and Image Acquisition

• Review the examination protocol based on the clinical indication provided in the order.
• Prepare the equipment, ensuring all calibration checks are green and the room is sanitized per infection control standards.
• Position the patient accurately using immobilization devices if necessary to minimize motion artifact.
• Apply radiation protection shielding to the patient (if applicable) in alignment with updated departmental guidelines.
• Execute the scan according to established technical parameters (kVp, mAs, slice thickness).
• Perform an immediate quality check of the raw images to ensure anatomical coverage and diagnostic clarity before dismissing the patient.

Section 3: Image Post-Processing and Radiologist Reporting

• Apply necessary post-processing (e.g., 3D reconstructions, Multi-Planar Reformats) and transmit images to the Picture Archiving and Communication System (PACS).
• Verify that the study has been pushed to the radiologist’s worklist.
• Flag "Critical Results" in the RIS/PACS system to trigger immediate notification to the referring physician.
• Ensure that preliminary reports or final sign-offs are completed within the departmental turnaround time (TAT) targets.

Section 4: Post-Examination Care and Facility Turnover

• Assist the patient in transitioning out of the exam room; provide post-contrast instructions if applicable (e.g., increased fluid intake).
• Complete all clinical documentation, including contrast media dosage, reaction notes, and fluoroscopy time.
• Perform terminal cleaning of the exam room, including table surface disinfection and equipment wipedown.
• Restock clinical supplies (gowns, contrast, IV kits) to prepare for the next patient.

Pro Tips & Pitfalls

• Pro Tip: Always utilize the "Read Back" method when receiving verbal orders from referring physicians to prevent communication errors.
• Pro Tip: Maintain a "clean desk" policy in the control room to reduce the risk of clerical errors during high-volume periods.
• Pitfall (Workflow Bottleneck): Failing to verify insurance authorization prior to the patient arriving in the suite is the leading cause of scheduling delays.
• Pitfall (Safety): Never assume a patient understands the radiation safety instructions; have them repeat the instructions back to you to ensure comprehension.

Frequently Asked Questions (FAQ)

1. What is the protocol for a patient who refuses a pregnancy test? If a patient of childbearing age refuses a pregnancy test for an ionizing radiation exam, the Radiologist must be notified immediately to conduct a risk-benefit assessment and provide clinical counseling. The patient may be required to sign a formal refusal/waiver form before proceeding.

2. How should "Critical Results" be communicated? Critical results must be communicated via a direct phone call to the ordering physician or a covering provider. An entry must be made in the EHR/PACS, documenting the name of the person contacted, the date/time of the call, and the specific information conveyed.

3. What steps are taken if an allergic reaction to contrast media occurs? The technologist must stop the injection immediately, alert the staff radiologist or the Rapid Response Team, and position the patient to maintain an airway. The Emergency Crash Cart must be brought to the room immediately, and the event must be documented in the department’s Safety Incident Reporting system.