Hospital Policies and Procedures

Mindanao Doctors Hospital and Cancer Center Inc.

National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on

Policy and Introduction of X-RAY, Radiology Responsible Party:
Procedures Department Vision, Mission, Goal,
Function and Mission

1. INTRODUCTION

X-ray were discovered in 1895 by Wilhelm Conrad roentgen (1845- 1923) who
was a Professor at Wuerzburg University in Germany. Working in with cathode-ray
tube in his laboratory, Roentgen observes a fluorescent glow of crystals on a table
near his tube. Roentgen discovered that very penetrating radiation was produce from
anode, which he called x-ray.
The Mindanao Doctor’s Hospital and Cancer Center Inc. Imaging Department
imaging is composed of three sections. Namely X-Ray Section, Ultrasound Section,
2d-Echo Section, Mammogram section and Ct scan Section. With these state- of-
the-art equipment and facilities, we will keep pace with advances in modern
medicine in each bid to efficiently serve the diagnostic and therapeutic needs of the
clients/patients.

2. RADIOLOGY DEPARMENT VISION/MISSION/GOAL

2.1 VISION

2.1.1 The Radiology staff shall have rendered good quality services to
attain the 100% patient’s satisfaction.

2.2 MISSION

2.2.1 To provide the most comprehensive services through constant

improvement of machine and of state of the art technologist. And
to provide cost effective, convenient, efficient, and appropriate
care for patients in need of radiologic technologic diagnosis,
therapy or intervention.

2.3 GOAL

2.3.1 To improve the good quality services for client satisfaction.

3. FUNCTION

The Radiologic Technologist Role Is very important in aiding the diagnostic and
treatment of illnesses and injuries. They are also responsible for getting a patient
ready for any radiological test treatments at the request of physicians. X-ray
machines, ultrasound machine, CT scan machine, Mammogram machine, are some
of the machines that the radiologic technologist operates. Radiologic Technologist
combine sophisticated medical scanning technology and person-to-person care to
care to create image used to diagnose and treat a wide variety of conditions.
Radiologic technologist performs much patient care function. Also known as
radiographers and Medical Imaging Technologist, this specialist procedure digital
images of parts of the human body for use in discovering a patient medical problem.
They are also involved in injecting special fluids into patients’ bloodstream for
diagnostic purposes. 2D-Echo Technician on the other hand, creates 2D and 3D
pictures of patient’s hearts through the use of high frequency sound waves and
special equipment. Prospective technician can seek a 2-year degree in medical
sonography or a similar field.

4. MISSION

4.1 The primary purpose of Diagnostic Services is to study anatomical

structures and physiological processes of the human body by acquiring
diagnostic images as well as performing therapeutic.

5. The Goals of the Diagnostic Services are:

5.1 To provide cost effective, convenient, efficient, and appropriate care for
patients in need of radiologic diagnosis, therapy or interventions.
5.2 To provide pertinent education for patient and patients family members.
5.3 To maintain and improve quality of care by performing quality control
tasks, as well as, continually evaluating and improving upon key
processes.
5.4 To provide training and education to all personnel to achieve excellence.
5.5 To exceed expectations of physician and patients regarding of quality
patient care.
5.6 To subscribe ALARA standards, maintaining radiation levels As Low As
Reasonably Achievable.

6. Approvals:

DR. ERVIN T. CASTILLO, MD, MBA-HA

Medical Director
 Hospital Policies and Procedures
Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on Scope of

Policy and Services Responsible Party:
Procedures

1. SCOPE OF SERVICES

1.1 To outline the scope of service for the Diagnostic Imaging Department.

1.1.1 PROCEDURE

1.1.1.1 This department is under the direct supervision of a

Radiologist, certified by the Radiologic Technologist and
having a current license from Professional Regulation
Commission (PRC).
1.1.1.2 Radiologic Technologists and certified by Professional
Regulation Commission (PRC) is available 24 hours per
day and will assist the radiologist(s) in acquiring needed
images on a referred patient.
1.1.1.3 Radiographs, commonly called x-rays, must be ordered
by an attending physician, and are taken by a certified
Radiologic Technologist. Following processing of the
radiographs, the radiologists dictate their interpretation.
1.1.1.4 Radiographic images are permanently stored in the
Picture Archiving and communication System (PACS).
1.1.1.5 The goal of the Department of Radiology will be to
ensure that all patients treated will receive high quality
care in the most expedient and professional manner
possible.
1.1.1.6 Although services include CT scanning, diagnostic
ultrasound and, x-ray procedures still constitute the
majority of the daily procedural load. Services related or
concomitant to imaging include quality assurance
monitoring and evaluation, quality control (including
protecting patients and staff from harmful radiation),
image interpretation, dictation, transcription, patient
 billing, marketing, equipment purchasing and continuing
education.
1.1.1.7 Portable x-ray equipment allows radiographs to be
obtained in surgery, as well as medical/surgical and
intensive care units.
1.1.1.8 All personnel within the department are under the
direction of the Diagnostic Imaging Department
Director.

1.2 To outline the scope of care at MINDANAO DOCTORS HOSPITAL AND

CANCER CENTER INC. (MDHCCI).

1.2.1 SERVICES OFFERED:

1.2.1.1 X-Ray
1.2.1.2 CT
1.2.1.3 Ultrasound
1.2.1.4 2D- Echo
1.2.1.5 Mammography

1.2.2 HOURS OF OPERATION:

1.2.2.1 Scheduled outpatient imaging services will be

offered and performed Monday through Friday from
7:00 AM to 7:00 PM, including holidays.

1.2.3 SCHEDULING:

1.2.3.1 All outpatient imaging requests are scheduled

through the Scheduling Department at (MDHCCI)
by calling.
1.2.3.2 All services requiring the administration of contrast
need to be scheduled in designated slots to
coordinate with the work schedule and on-site
availability of physician.

1.2.4 PATIENT REQUESTS:

1.2.4.1 All outpatient requests must have a written order

from a licensed physician or practitioner.
1.2.4.2 The Scheduling Department will obtain pre-
authorization, if necessary, and provide patient
information, contact number and instructions
pertaining to their appointment and exam.
1.2.4.3
Approvals:

DR. ERVIN T. CASTILLO, MD, MBA-HA

Medical Director
 Hospital Policies and Procedures
Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on SOP in

Policy and Radiology Department Responsible Party:
Procedures

1. SOP IN RADIOLOGY DEPARTMENT

1.1 X-RAY Procedure
1.1.1 CHEST X-RAY
1.1.1.1 Patient should remove necklace and bra to avoid
artifacts on body fields.
1.1.1.2 Patients should wear patient’s gown in any
procedure.
1.1.1.3 Put on gonadal shield for pregnant women to
protect the fetus from radiation in taking x-ray
examination.
1.1.1.4 ADULT/PEDIA CHEST
View
1.1.1.4.1 PA
1.1.1.4.2 Inspiration
1.1.1.4.3 PA Expiration
1.1.1.4.4 Lateral
1.1.1.4.5 Lateral Decubitus
1.1.1.4.6 Oblique
1.1.1.4.7 AP – Lordotic
1.1.1.4.8 AP – Apical
1.1.1.4.9 AP - Portable

1.1.2 SKULL X-RAY

1.1.2.1 Patient should remove earrings for women/ and
necklace to avoid artifacts as part of being x-rayed.
1.1.2.2 Instruct patients no extra movements until the
procedure is being done.
 1.1.2.3 SKULL ADULT/PEDIA
View
1.1.2.3.1 AP
1.1.2.3.2 PA (Caldwell)
1.1.2.3.3 PA (Caldwell)15
1.1.2.3.4 PA (Caldwell) 25-30°
1.1.2.3.5 PA (Haas)
1.1.2.3.6 Townes
1.1.2.3.7 Lateral
1.1.2.3.8 Submentovertex

1.1.3 ABDOMEN AND PELVIC X-RAY

1.1.3.1 Patients should wear gown.
1.1.3.2 Patients should lower their pants/shorts with zipper
or any metal buttons that might be cause of false
interpretations of part being x-rayed

1.1.3.3 ABDOMEN ADULT/PEDIA

View
1.1.3.3.1 Supine
1.1.3.3.2 Erect
1.1.3.3.3 Decubitus
1.1.3.3.4 Dorsal Decubitus
1.1.3.3.5 Lateral

1.1.4 HAND/ WRIST X-RAY

1.1.4.1 Patients should remove bracelet/watches/rings to

avoid artifacts on part being examined that might
be cause of false interpretation of x-ray result.

1.1.4.2 HAND/WRIST ADULT/PEDIA

View

1.1.4.2.1 PA/AP
1.1.4.2.2 Oblique
1.1.4.2.3 Lateral

1.1.5 LEG/FOOT X-RAY

1.1.5.1 Patients should remove shoes before taking foot

x-ray.
1.1.5.2 Patients should folded-up his pants in taking leg x-
ray.
 1.1.5.3 Instruct patients no extra movements until
procedure is being done.
1.1.5.4 View
1.1.5.4.1 Medial Oblique
1.1.5.4.2 Lateral Oblique
1.1.5.4.3 Lateral
1.1.5.4.4 Dorsoplantar (DP)

1.2 ULTRASOUND PROCEDURES

1.2.1 With Preparation
1.2.1.1 Whole abdomen and Hepatobiliary Tract
Ultrasound - 6 to 8 hours fasting
1.2.1.2 KUB Ultrasound - Full bladder
1.2.1.3 KUB/Prostate Ultrasound - Full bladder
1.2.1.4 Prostate Gland - Full bladder
1.2.1.5 Uterus (Not Pregnant) - Full bladder

1.2.2 Without Preparation

1.2.2.1 Breast Ultrasound
1.2.2.2 Spleen Ultrasound
1.2.2.3 Cardiac Ultrasound
1.2.2.4 Thoracic Ultrasound
1.2.2.5 Cranial Ultrasound
1.2.2.6 Thyroid Ultrasound
1.2.2.7 Inguino-Scrotal Ultrasound
1.2.2.8 TVS Gyne/O
1.2.2.9 Kidneys Ultrasound
1.2.2.10 Liver Ultrasound
1.2.2.11 Neck Ultrasound
1.2.2.12 Pelvis (Pregnant)
1.2.2.13 Ultrasound Guided Procedures
1.2.2.14 Soft Tissue Ultrasound

1.3 CT SCAN PROCEDURES

1.3.3.1 Whole Abdomen Ct scan Plain or with contrast

1.3.3.2 Cranial Ct scan Plain or with contrast
1.3.3.3 Ct scan of the Paranasal Sinuses
1.3.3.4 Chest Ct scan Plain or with contrast
1.3.3.5 Stonogram

2. Approvals:
 DR. ERVIN T. CASTILLO, MD, MBA-HA
Medical Director

Hospital Policies and Procedures

Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on Patient

Policy and Care Guidelines for Diagnostic Responsible Party:
Procedures Imaging Staff

1. PATIENT CARE GUIDELINES FOR DIAGNOSTIC IMAGING STAFF

1.1 To have a keen sense of all our patient’s feelings and needs, and to be
perceived by all others (both internal and external) as a knowledgeable,
understandable, helpful and caring resource. To make all patients feel
special.

1.1.1 PROCEDURE

1.1.1.1 Professionalism and appearance – to look and

conduct oneself in a manner perceived as positive by all
others, both internal and external. To create a work
environment that projects an image of excellence.

1.1.1.1.1 Dress code adhered to.

1.1.1.1.2 Managing emotions and stress at all times
in all situations.
1.1.1.1.3 Proper knowledge, use and care of
equipment in all areas of assigned work
1.1.1.1.4 Clean, safe and organized work area.
1.1.1.1.5 Accurate record keeping.

1.1.1.2 Knowledge and expertise – to be perceived as

knowledgeable and up-to-date in the field of
radiological technology and all the services offered
by the department.
 1.1.1.2.1 Possess knowledge of all the services
offered with the ability to guide and describe
each modality to doctors, nursing,
interdepartmental staff, clinic personnel, lay
people, etc.
1.1.1.2.2 Have equipment knowledge and annual
proficiencies reviewed and documented.
1.1.1.2.3 Keep up-to-date in the field of radiology and
areas of expertise, by attending seminars,
in-services, and organizational/professional
meetings.
1.1.1.2.4 Network with staff at other hospitals and/or
clinics.
1.1.1.2.5 Adhere to radiation protection and safety
guidelines at all times in all situations.
Follow ALARA (to keep all radiation
exposure as low as reasonably achievable).
Shield all patients, especially those of
childbearing age.

1.1.1.3 Communication and projection–Communicate

positively with all internal and external customers
and project through communication,
professionalism, knowledge and high standards.

1.1.1.3.1 Be sensitive to people of different cultural

and religious backgrounds. They may view
illness and treatment methods differently.
1.1.1.3.2 Patient and their families, many of whom
may not speak or understand
Tagalog/Bisaya/Maguindanaon, need to
know that the hospital staff is acting in their
best interest. (Please ask for assistance in
communication when needed. There are
staff members who speak different
languages who may be of assistance.)
1.1.1.3.3 Always use appropriate and effective
delivery and tonal quality.

1.1.1.4 Geriatrics and pediatrics –Caring for the

adolescent or geriatric patient can present unique
challenges for the technologist or nurse. Each age
group has particular anxieties and concerns. It is up
to the technologist or nurse to provide an
understanding, supportive, and compassionate
 environment. All staff members who assess, treat,
or care for these patients should be able to
understand, adjust and meet their special needs.

1.1.1.4.1 Geriatrics

1.1.1.4.1.1 Address each client appropriately and

professionally at his or her level. (i.e.
Adult) “Hello, Mr. Zach. My name is
Emarie and I will be performing your
CT exam today.”
1.1.1.4.1.2 Never ignore your patient, even
though you may think they do not
hear or understand.
1.1.1.4.1.3 Address them appropriately and
explain what you are going to do
before you do it.
1.1.1.4.1.4 Never call an elderly patient “sweetie,
honey, or dear”; use their respectful
title or name.
1.1.1.4.1.5 Never treat an elderly patient like a
child.
1.1.1.4.1.6 Never leave a patient unattended.
Always put up the side rails on carts.
Always check to make sure the brake
is set on the cart or wheelchair for
patient safety.

1.1.1.4.2 Pediatrics

1.1.1.4.2.1 Address each client appropriate and

professionally at his or her level. (i.e.
Child) “Hi, Emarie. My name is Zach
and I am going to take a picture of
your chest today with a special
camera that can see inside of you.
Maybe we will be able to see why you
have been coughing so hard.”
1.1.1.4.2.2 Do not confuse children by using
technical terms. Talk to them on their
level, and look at them directly when
speaking to them.
1.1.1.4.2.3 Praise them for holding still and
cooperating with you.
 1.1.1.4.2.4 Demonstrate what you are going to do
before you do it.
1.1.1.4.2.5 Always shield children, and
document such on the requisition.
1.1.1.4.2.6 Let the parents know what you are
going to do. If the mother is not
pregnant, you may ask her to help
with the child (be sure to give her a
lead apron to wear, and note on the
requisition that the mother stated she
was not pregnant and was given a
lead apron for radiation protection).
Children are more comfortable with
their parents nearby in strange
surroundings and situations.
1.1.1.4.2.7 Never leave children unattended.

1.1.1.5 Customer focus – Understand and service

customers’ needs and wants to meet their
expectations.

1.1.1.5.1 Know what your customer wants.

1.1.1.5.2 Be a key link to the patient care effort.
1.1.1.5.3 Market your department and educate others
of your services.

1.1.1.6 Standards – Set and adhere to high work

standards that are noticed and regarded as positive
by all others.

1.1.1.6.1 Follow the organizational values, vision and

mission statement.
1.1.1.6.2 Produce high quality radiographs at all
times.
1.1.1.6.3 Have ownership and accountability of work.
1.1.1.6.4 Have pride in work and the department.
1.1.1.6.5 Set high levels of performance.
1.1.1.6.6 Be flexible to continue to meet the demands
of the healthcare field of today and
tomorrow.
1.1.1.6.7 To follow the RT and RN Code of Ethics at
all times.

2. Approvals:
 DR. ERVIN T. CASTILLO, MD, MBA-HA
Medical Director

Hospital Policies and Procedures

Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on Job

Policy and description on Staff and Personnel Responsible Party:
Procedures

1. JOB DESCRIPTION ON STAFF AND PERSONNEL

1.1 CHIEF RADIOLOGIC TECHNOLOGIST

1.1.1 Checks radiology census.

1.1.2 Check department supplies and do requisition as necessary.
1.1.3 Supervises the operation of radiologic imaging devices to
generate images of the body.
1.1.4 Records processes and maintains patient information and
therapeutic records, and prepares report.
1.1.5 Coordinates work with other technologist and healthcare
personnel.
1.1.6 Takes care of the maintenance and emergency repairs in the
radiographic equipment.
1.1.7 Trains and supervise and imaging staff. Makes schedule and
assignment of staffs. Checks and counter signs the
documentation done by the staff. Plans and organize staffing
pattern.
1.1.8 Establishes, promotes and maintain a good interpersonal
relationship within the department.

1.2 RADIOLOGIC TECHNOLOGIST

1.2.1 Set-up the examination rooms. Sees to it that required devices

and machines are functional.
1.2.2 Check department supplies and do requisition if necessary.
 1.2.3 Responsible for explaining and getting patients ready for
radiological test and treatment that will be performed.
1.2.4 Position patient on the x-ray examination table.
1.2.5 Maneuver imaging device to desire position. Adjust the control
of the equipment to fix the time of exposure and distance.
1.2.6 Utilize radiation safety measures and protection of equipment
to fulfill
1.2.7 Government norms as well as to guarantee the safety of
patients and the workforce.
1.2.8 Operates x-ray device to generate images of the body.
1.2.9 Records, processes and maintains patient information and
therapeutic records and prepares reports.
1.2.10 Coordinate work with other technologist and health care
personnel.
1.2.11 Ensures that radiology equipment is properly maintained.
1.2.12 Establishes, promotes and maintains a good interpersonal
relationship within the department.

1.3 ECHO TECHNICIAN

1.3.1 Prepares both the patient and diagnostic equipment for

imaging procedure.
1.3.2 Assist and position the patient comfortably on the examining
table. Applies gel
1.3.3 That aids in sound transmission to the patient’s skin before
using the diagnostic equipment to create images of the
patient’s heart.
1.3.4 May responsible also for ensuring that the records are kept
properly for the procedure

2. Approvals:

DR. ERVIN T. CASTILLO, MD, MBA-HA

Medical Director
 Hospital Policies and Procedures
Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on Ordering

Policy and exams, Patient assessment and care Responsible Party:
Procedures of Critically ill patient.

1. ORDERING EXAMS

1.1 To ensure that only appropriate exams are performed.

1.1.1 PROCEDURE:

1.1.1.1 Exams shall be performed only upon the order of a

person who is lawfully authorized to diagnose, treat
and prescribe.
1.1.1.2 All requests for exams should contain the reasons
for the examination. The requesting medical staff
member is responsible for providing this
information.
1.1.1.3 In the case of inpatients, the requisition or order for
examination should be provided in compliance with
the hospital’s established procedure.
1.1.1.4 In the case of outpatients, a physician’s prescription
should be provided.
1.1.1.5 All requisitions on inpatients shall be verified
against the physician’s orders on the patient’s chart
or prescription. Any contraindication requires an
immediate call to the referring physician for
clarification of the order.
 1.1.1.6 Once the order or prescription is confirmed, check
the patient’s ID bracelet or otherwise establish the
patient’s identity to make sure the correct patient is
being scanned. Always verify the patient identity
twice, by name and date of birth.

2. ORDERING EXAMS FOR OUTPATIENTS

2.1 To ensure that only appropriate exams are performed.

2.1.1 PROCEDURE

2.1.1.1 Exams shall be performed only upon the

order of a person who is lawfully authorized to
diagnose, treat and prescribe.
2.1.1.2 All requests for exams should contain the
reasons for the examination. The requesting
medical staff member is responsible for
providing this information.
2.1.1.3 For outpatients, a physician’s prescription
should be provided.

3. PATIENT ASSESMENT

3.1 Patient assessment is made with the interdisciplinary approach of the

physician, nursing and the Diagnostic Imaging Department technologist to
provide the most relevant information to allow for the optimum radiological
exam and results.

3.1.1 PROCEDURE:

3.1.1.1 It is the policy that the assessment of patients

undergoing diagnostic imaging procedures Takes
place in the following manner:

3.1.1.1.1 A history of the patient’s condition will be

reviewed prior to the test being performed
3.1.1.1.2 A written order will be reviewed by the
radiologist and technologist.
3.1.1.1.3 The patient will be questioned about his/her
condition by the technologist or radiology
nurse and the information documented on
the requisition for the radiologist to review.
 3.1.1.1.4 Verbal communication between the ordering
physician and the radiologist is encouraged.
3.1.1.1.5 Technologists and nursing will assess the
patient during the procedure being
performed.
3.1.1.1.6 If the patient condition changes, it will be
reported to the radiologist or ordering
physician immediately.
3.1.1.1.7 All actions necessary for response to an
adverse reaction will be documented by
staff and reported in Quantros.
3.1.1.1.8 The radiology nurse will be available for pre
and post monitoring when necessary.

3.2 CARE OF CRITICALLY ILL PATIENT

3.2.1 Establish guidelines for the care of the critically ill patient in
the Department of Diagnostic Imaging.

3.2.1.1 PROCEDURE:

3.2.1.1.1 A Registered Nurse must accompany the

patient to and from the Department of
Radiology as well as remaining during the
entire x-ray procedures.
3.2.1.1.2 The x-ray room must be prepared to
accommodate the patient in case of
emergency (oxygen, crash cart, suction,
etc.).
3.2.1.1.3 Expediency of the exam is emphasized.
The technologist shall utilize the
radiographic and auxiliary equipment to its
maximum potential and shall always be
alert to the patient's condition.
3.2.1.1.4 When radiography is required for a patient
in the room or at bedside, the technologist
will always report to the nurse in charge on
the ward, station or floor.
3.2.1.1.5 The technologist will check the patient ID
and verify the patient name and date of
birth.
3.2.1.1.6 The technologist should remember the
directions and cautions the charge nurse
communicated concerning the patient, and
make any necessary adjustments to
accommodate the patient's special needs
and/or condition.
 3.2.1.1.7 When it is necessary to change a patient's
position, the rules of body mechanics shall
be observed, to safely and comfortably lift
and move the patient.
3.2.1.1.8 After completion of radiographic procedure,
the technologist shall make the patient
comfortable and advise the charge nurse of
the completion of the examination

4. RADIOLOGIC EXAMINATIONS IN PREGNANT PATIENTS

4.1.1 To assure that all reasonable steps are taken to protect an

unborn child during radiological exams.

4.1.1.1 PROCEDURE:

4.1.1.1.1 All female patients will be asked if they may be

pregnant prior to the examination.
4.1.1.1.2 A written informed consent is required in the
event that a radiological exam must be
performed on a pregnant patient.
4.1.1.1.3 The pregnant patient will be shielded and
technique adjusted to be as low as possible
without compromised diagnostic quality.
4.1.1.1.4 The radiologist is to be made aware of the
scheduled procedure.
4.1.1.1.5 The radiologist will contact the referring
physician to discuss possible alternatives or
modifications of the exam to minimize exposure
to thefetus/embryo.
4.1.1.1.6 Due to emergency, if informed consent cannot
be obtained, the radiologist will document in the
medical record the reason for the exam and
steps taken to minimize risks to the
embryo/fetus.

5. Approvals:
 DR. ERVIN T. CASTILLO, MD, MBA-HA
Medical Director

Hospital Policies and Procedures

Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on Policies

Policy and and Rules of the Radiology Responsible Party:
Procedures Department

1. POLICIES/RULES OF THE RADIOLOGY DEPARTMENT

1.1 SCOPE

1.1.1 These policies/rules shall apply to all diagnostic X-ray

examination of MINDANAO DOCTOR’S HOSPITAL AND
CANCER CENTER INC.

1.2 DEFINITION OF TERMS

1.2.1 EXPOSURE - is a measure of quantity of X or gamma

radiation based upon its ability to ionize air through which it
passes.

1.2.2 GONADAL SHIELD - is a radiation absorbing material which

is used to reduce the radiation exposure.

1.2.3 PROTECTIVE APRON- is an apron made of absorbing

material (LEAD) to reduce the radiation exposure.

1.2.4 PROTECTIVE GLOVE- is a glove or hand shield made with

radiation absorbing material to reduce radiation exposure on
hand
 1.2.5 RADIOLOGIC/ X-RAY TECHNOLOGIST- is a person who is
qualified to used or Operate an x-ray machine.

1.3 IMAGING TECHNOLOGIST RESTRICTIONS

1.3.1 To insure appropriate patient care is provided by the delivery

of results of procedures through the proper channels to avoid
misdiagnosis and/or treatment.

1.3.1.1 PROCEDURE:

1.3.1.1.1 It is the policy of the Diagnostic Imaging

Department that all technologists working in
the department will not work beyond their
scope of practice.
1.3.1.1.2 Technologists will not perform any
diagnostic procedure without the written
order of a physician.
1.3.1.1.3 All technologists work under the
supervision of the radiologists.
1.3.1.1.4 Technologists will not make a diagnosis
based on any radiograph or image.
1.3.1.1.5 Technologists will not operate any
equipment without having been trained to
operate it safely and effectively.
1.3.1.1.6 Technologists will not report results to any
patient; this shall be done by the physician
or the radiologist.
1.3.1.1.7 Technologists will not perform breast
palpations except to position the breast for
radiographic purposes.

1.4 PATIENT SHIELDING

1.4.1 To insure patient safety during radiographic

procedures/examination.
1.4.2 It is the policy that appropriate measures will be taken to
protect patients from unnecessary direct and scatter radiation
through the following measures:
1.4.2.1 All females of childbearing age will be shielded with
a lead apron.
1.4.2.2 The technologist will ensure that all children being
radiographed have proper gonadal shielding and
that proper collimation of the x-ray machine be
utilized to expose only the area or anatomy of
interest.
1.4.2.3 All expectant females will be properly shielded and
the x-ray collimated to the area or anatomy of
interest only. Orders should be carefully considered
against the risks.
 1.4.2.4 Expectant females MUST NOT be allowed to hold
or immobilize children for radiographs and they
WILL NOT be allowed in the x-ray area during
exposures.

1.5 PROTECTIVE APPAREL QUALITY ASSURANCE

1.5.1 To maintain quality assurance of lead aprons used to reduce

exposure to radiation.
1.5.1.1 Gather lead aprons.
1.5.1.2 Document lead apron number and status of apron
on appropriate form.
1.5.1.3 Document disposal of aprons that show evidence of
cracks or radiation permeation in the body of the
apron.
1.5.1.4 Notify manager of aprons that must be discarded so
that a replacement apron may be ordered.
1.5.1.5 A record of all discarded lead aprons and the
reason for the discard will be kept on file.
1.5.1.6 Radiological technologist is responsible to evaluate
quality of lead aprons in Diagnostic Imaging,
Operating Room, Special Procedures and
Ambulatory Surgery.
1.5.1.7 Department manager will be notified of any defects
in lead aprons.
1.5.1.8 Department managers will be responsible for
reordering new aprons as defective aprons are
destroyed.
1.5.1.9 Department managers will be responsible for
notifying Diagnostic Imaging Manager of new
aprons acquired.
1.5.1.10 Newly acquired aprons will be tagged with a
number, inspected and added to the list for
subsequent annual inspections.
1.5.1.11 Findings of the lead apron inspection report will be
logged by the Radiology Administrative Assistant
and verified for accuracy by the Radiologic
technologist who scanned the aprons.
1.5.1.12 Personal lead aprons will not be used for any
purpose in the facility.

6. Approvals:
DR. ERVIN T. CASTILLO, MD, MBA-HA
Medical Director

Hospital Policies and Procedures

Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on Radiation

Policy and safety of Radiology Department Responsible Party:
Procedures

1. POLICIES ON RADIATION SAFETY OF RADIOLOGY DEPARTMENT

1. All radiation workers shall be provided with personal radiation dose

monitors (OSL) to measure the radiation dose absorbed by the individual
and these shall kept in file.
2. A red warning light build that is automatically illuminated when the X-RAY
is switched on located outside the X-RAY ROOM DOOR.
3. Proper signage or warning notices shall be conspicuous areas for
patient’s safety as “X-RAY ROOM DO NOT ENTER WHEN THE RED
LIGHT IS ON”.
4. X-ray room shall be provided with the following radiological accessories:
1.4.1 Caliper
1.4.2 A set of gonadal shield with minimum lead equivalent of 0.5mm
which includes contact shields for male adult, female adult and
infant male and female, an upright gonadal shield for chest
examination, a pair of lead rubber gloves or lead hand protector.
5. To minimize an unintentional irradiation of the embryo of fetus a notice. IF
IT IS POSSIBLE THAT YOU MIGHT BE PREGNANT NOTIFY THE
PHYSICIAN BEFORE YOU X-RAY EXAMINATION.
6. Proper disposal of used and developing solutions and developer shall be
observed.

7. OCCUPATIONAL EXPOSURE MONITORING

 1.7.1 It is the policy of MINDANAO DOCTORS HOSPITAL AND
CANCER CENTER INC.(MDHCCI) to monitor personnel working
with or around radiation emitting sources or devices and who are
likely to receive 10% of the annual radiation dose limits identified
in by the TÜV Rheinland Philippines Inc. Agency PURPOSE :

1.7.1.1 The purpose of this policy is to establish guidelines to

ensure personnel exposures to radiation are maintained
as low as reasonably achievable (ALARA) and meet the
(MDHCCI) ALARA goals.

8. AUTHORITY AND RESPONSIBILITY

1.8.1 Office of Radiation Safety is responsible for:

1.8.1.1 Providing radiation monitoring devices as requested by

personnel.
1.8.1.2 Ensure appropriate personal monitoring equipment is
provided for the type or radiation to be monitored.
1.8.1.3 Providing instructions to personnel on how to wear
personal monitoring equipment.
1.8.1.4 Reviewing personnel monitoring reports.
1.8.1.5 Investigating causes for employee exposures which
exceed the ALARA investigational limits or have
abnormally high exposure quarterly readings.

9. Employees are responsible for:

1.9.1 Wearing the personal monitoring equipment (dosimeter) assigned

while working in areas where radiation emitting sources or devices
are used and/or stored.
1.9.2 Making sure that the dosimeter does not leave SVRHC property at
any time except when being sent out for development and
reading.
1.9.3 Making sure that the dosimeter for a particular wear period is
exchanged for a dosimeter for the new wear period by the return
due date.
1.9.4 Informing the Radiation Safety Officer, in writing, if they want to
declare their pregnancy.
1.9.5 Using appropriate ALARA principles (time, distance and shielding)
when required or applicable to maintain individual exposure to
within ALARA levels.

10. MONITORING REQUIREMENTS

 1.10.1 All persons whose work is associated with radiation that could
result in exposure above 10% of the above limits must wear
radiation monitoring badges (5% for persons fewer than 18 years
of age). * Whole body badges and extremity badges are issued for
a three-month wear cycle and are used to monitor exposure from
high energy beta, gamma-ray, and neutron sources.
1.10.2 Employees whose work is associated with radiation from X-ray
producing equipment and are likely to receive exposure in excess
of 10% of the annual dose limits must wear radiation monitoring
badges (dosimeters).
1.10.3 A declared pregnant women must be monitored if she is likely to
receive during the entire pregnancy, from radiation sources
external to the body, a deep dose equivalent in excess of 1 mSv
(0.1 rem) or is likely to receive a committed effective dose
equivalent in excess of 0.5 mSv (0.05 rem). Pregnant employees
have the option to voluntarily declare their pregnancy, in writing, to
the Radiation Safety Officer. Declaration of the pregnancy allows
the radiation exposure to the fetus to be closely monitored and
allow for additional precautions, if needed. If you should have any
questions, please contact the Office of Radiation Safety.

1.10.3.1 Exposure Limits - Quarterly

1.10.3.1.1Total Effective Dose Equivalent (TEDE) [Exposure to

the Whole Body]: 1,250 mRem.
1.10.3.1.2Shallow Dose Equivalent (SDE) [Exposure to the Skin
or any Extremity]: 1,875 mRem
1.10.3.1.3Minor Dose Limits [Less than 18 years old]: 10% of
Adult Doses listed in Items 1 – 3 above
1.10.3.1.4Declared Pregnant Worker [Dose Equivalent to an
Embryo/Fetus]: 500 mRem during the gestation period

11. REQUESTING OR CANCELING RADIATION MONITORING BADGES

1.11.1 To initiate monitoring service for exposure to radiation an

individual must complete all information on the radiation
monitoring request sheet. This will ensure the proper monitoring
device(s) is issued to the individual and will assist in determining if
the individual has any previous exposure history. The individual
shall submit the request sheet to their manager for signature. The
completed request sheet shall be submitted to the Office of
Radiation Safety.
1.11.2 The Office of Radiation Safety will issue the monitoring device(s)
to the individual as noted on the request sheet.
 1.11.3 Radiation monitoring badges must be ordered and discontinued
by the Office of Radiation Safety several weeks in advance. The
manager must submit request sheets in our office by the 15th of
the month to ensure that a permanent badge is started or
canceled effective the first of the following month.

12. LOCATION OF INDIVIDUAL MONITORING DEVICE

1.12.1 The radiation monitoring device shall be worn in the appropriate

location on the whole body or extremity as follows:
1.12.2 The whole body monitoring device shall be worn at the unshielded
location of the whole body likely to receive the highest exposure.
Note: When a protective apron is worn, the location of the
monitoring device is typically at the neck (collar). The whole body
means, for purposes of external exposure, head, trunk (including
male gonads), arms above the elbow and legs above the knee.
1.12.3 The extremity monitoring device shall be worn on the extremity
likely to receive the highest exposure and shall be oriented on the
appropriate finger (label inward toward palm) to measure the
highest dose to the extremity being monitored. The extremity
badge must be protected from contamination; therefore, it must be
worn under gloves when you are working with unsealed
radioactive material.
1.12.4 The monitoring device to monitor the dose to an embryo/fetus of a
declared pregnant woman shall be located at the waist under any
protective apron being worn by the woman.
1.12.5 Radiation monitoring badge should remain in a secure area and
should not be taken home after normal work hours.
Please Note: Radiation monitoring badges are to be worn only by
the individual to whom they are assigned to.
2. Approvals:

DR. ERVIN T. CASTILLO, MD, MBA-HA

Medical Director

Hospital Policies and Procedures

Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on

Policy and Departamental Safety, Responsible Party:
Procedures

1. DEPARTMENTAL SAFETY

1.1 To assure safety of all employees and patients:

1.1.1 The Diagnostic Imaging Department Manager is

responsible for maintaining safety standards,
developing and refining safety rules, and supervising
and training personnel in departmental standards.
1.1.2 The Diagnostic Imaging Department Manager is
responsible for notifying the Safety Officer in case of
any safety hazard.
1.1.3 All Diagnostic Imaging Department employees shall
report defective equipment, unsafe conditions, acts or
safety hazards to the Manager.
1.1.4 Smoking or the consumption of alcoholic beverages will
not be allowed at any time, while on duty.
1.1.5 Proper body mechanics and lifting techniques will be
observed at all times.
1.1.6 Electrical cords will be clear of traffic areas. Electrical
extension cords will not be used without written
approval from the Physical Plant. Physical Plant
 personnel will inspect all personal electrical appliances
before use. All electrical machines with heat producing
elements must be turned off or unplugged when not in
use.
1.1.7 Only authorized personnel will be allowed to operate
diagnostic imaging equipment.
1.1.8 Faulty equipment will be reported to the Physical Plant
or the vendor, per policy.
1.1.9 Equipment and furniture must be arranged to allow
adequate passage and access to exist at all times.
1.1.10 The employee who discovers a spill will clean up minor
spills, such as water. This is to be done immediately.
Environmental Services will clean up major spills.
1.1.11 The Physical Plant will be notified immediately of
improper illumination and/or ventilation.
1.1.12 Scissors, knives, pins, razor blades and other sharp
instruments must be stored and used safely. Use of
sharp spindles is prohibited.
1.1.13 File drawers and cabinet doors will be closed when not
in use.
1.1.14 Employee clothing will be in accordance with hospital
policy.
1.1.15 Only authorized personnel shall be allowed in exam
rooms.
1.1.16 Transport or technologist who calls for patient will check
the ID band on the patient's wrist to verify correct
patient identity.
1.1.17 Outpatients will be asked date of birth and/or to give full
name and spelling of name.
1.1.18 A “Radiology Hand-off Communication Form” must be
completed by the patient’s nurse BEFORE transporting
to the Diagnostic Imaging Department.
1.1.19 Employees will be aware of location of fire extinguishers
and fire exits. Employees will be educated in
evacuation of area during a fire code.

2. Approvals:

DR. ERVIN T. CASTILLO, MD, MBA-HA

Medical Director
 Hospital Policies and Procedures
Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on Radiology

Policy and Rule For Quality Control Program Responsible Party:
Procedures

1. RADIOLOGY RULE FOR QUALITY CONTROL PROGRAM

1.1. All request for x-ray examination should be made in writing and
should contain the following:

1.1.1 Patients name, age sex, birthday, middle name, status and
address.
1.1.2 Patient’s hospital number.
1.1.3 Time and date when request was made.
1.1.4 Clinical diagnosis.
1.1.5 Type of examination.
1.1.6 Specific examination desired.
1.1.7 Name of requesting physician and his signature.
1.1.8 Name radiology staffs who receive the request.

1.2 In case need for the radiology staff to go enter the patient’s room the
staff of technologist should conduct himself as follows:

1.2.1 He should identify himself.

1.2.2 He should state the reason for his presence.
1.2.3 Prior to any procedure, he must identify the patients by
checking the patients arm band, name and hospital
number.
1.2.4 (Note: Patient must not be identified by bed
number, if there is in doubt, the floor nurse/ nurse
on duty must identify the patient.)
1.3 For purposes of Good Record Keeping the following must be
observed.

1.3.1 Any request for X-ray examination must be kept

preserved for future reference.
1.3.2 Whenever possible a record must be containing the
patient’s identification.
1.3.2.1 In performing x-ray procedure the
following must be observed:
1.3.2.2 Explain the procedure to patients.
1.3.2.3 Instruct the patients to remove metals on
the body such as:

1.3.2.3.1 Earrings
1.3.2.3.2 Wrist bond
1.3.2.3.3 Coins
1.3.2.3.4 Necklace

1.4 Anatomical Site Check

1.4.1 To insure the correct anatomical site is radiographed or

the correct side (left or right) is correctly identified
before any interventional imaging procedure is
performed.
1.4.2 It is the policy of the Department of Radiology and
Diagnostic Imaging that all patients undergoing any
imaging procedure are to have the correct site identified
before the exam begins in order to insure patient safety.
1.4.3 To achieve the above, the following safety measures
will be followed:

1.4.3.1 The technologist will check for the correct

patient by two means, i.e., the patient’s
name and date of birth.
1.4.3.2 The technologist will confirm the spelling
of the name and confirm the date of birth.
1.4.3.3 The technologist will check the written
order to verify “left” or “right”.
1.4.3.4 The technologist will ask the patient on
which side they are having the procedure
performed and to point to the specific
area.
1.4.3.5 The technologist will place a “spot-
marker” on the all extremities where the
patient is having pain.
 2. Approvals:

DR. ERVIN T. CASTILLO, MD, MBA-HA

Medical Director

Hospital Policies and Procedures

Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on Infection

Policy and Control Guidelines Responsible Party:
Procedures

1. INFECTION CONTROL GUIDELINES

1.1 To ensure consistency with the implementation of infection control

guidelines within the Diagnostic Imaging department.

1.1.1 Personnel

1.1.1.1 Employee health guidelines will be

followed by all employees of the
Radiology and Diagnostic Imaging
department.

1.1.2 General infection control practices

1.1.2.1 Careful hand hygiene must be practiced

as outlined in the hospital infection
control manual. Hand hygiene must be
performed after patient contact, contact
with contaminated items, or contact with
mucous membranes.
1.1.2.2 Standard precautions will be followed for
all patients. Body substances from all
 patients are to be considered potentially
infectious.
1.1.2.3 Isolation precautions will be observed as
appropriate. Specific precautions and
indications for isolation can be found in
the hospital infection control manual.
1.1.2.4 Linen is to be changed between each
patient. Clean linen is stored in a closed
cupboard. Soiled linen is disposed of in
dirty linen hampers within the
department.
1.1.2.5 Disposable items are for single patient
use only and discarded after use.
1.1.2.6 Sterile patient care items will be kept in
closed cupboards. All supplies will be
checked for outdates periodically and
prior to patient use for damage to outer
package.
1.1.2.7 During sterile procedures, only personnel
involved in the procedure are permitted in
the room.
1.1.2.8 Exam tables/Bucky’s/patient contact
surfaces in all imaging areas (Ultrasound,
X-ray, CT, and will be cleaned between
each patient with an Infection Control
Committee approved disinfectant.
1.1.2.9 Instruments/sterile trays are returned to
Sterile Processing for decontamination
and sterilization. Items must be
transported in a closed bag/container,
which is labeled as biohazard.
1.1.2.10 A schedule for routine cleaning of all
portable equipment must be maintained
and cleaning must be documented. In
addition, portable equipment must be
cleaned prior to entering a surgical suite
and upon leaving an isolation room.
1.1.2.11 Laboratory specimens should be
collected in a careful manner. Prior to
transport, tubes or slides must be placed
in a plastic bag and sealed. The bag
must be labeled as biohazard.
1.1.2.12 Sterile technique must be observed when
starting IV lines or inserting urinary
catheters.
 1.1.2.13 Care must be taken when handling
contaminated sharps. Used syringes
must be disposed of in an appropriate
puncture resistant biohazard container.
1.1.2.14 Injectable fluids must be checked for
expiration date and any sign of
degradation (cloudiness or particulates)
prior to use.
1.1.2.15 Sonographic probes that will have
contact with mucous membranes should
be covered with a latex barrier, if
possible. Probes must be cleaned and
high-level disinfected after use.

2. Approvals:

DR. ERVIN T. CASTILLO, MD, MBA-HA

Medical Director
 Hospital Policies and Procedures
Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on Linen

Policy and Usage at the Radiology Department Responsible Party:
Procedures

1. LINEN USAGE AT THE RADIOLOGY DEPARTMENT

1.1 To establish a policy and procedure for cost efficient linen usage in the
Imaging Department.

1.1.1 PROCEDURE

1.1.1.1 Linens will be stored in the following

locations:

1.1.1.1.1 Ultrasound Room 1

1.1.1.1.2 X-ray Room 1
1.1.1.1.3 CT Exam Room

1.1.2 Linens will be stored in a linen cabinet.

1.1.3 Section leaders maintain an inventory of linens in the
section for whichthey are responsible.
1.1.4 One sheet and one pillowcase are acceptable for each
patient, as well as a blanket, as necessary.
1.1.5 One or two gowns may be used for each patient,
depending on need. If a gown is soiled, it will be
replaced with a clean one.
1.1.6 White washcloths and towels are for patient use.
2. Approvals:

DR. ERVIN T. CASTILLO, MD, MBA-HA

Medical Director

Hospital Policies and Procedures

Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on Lost and

Policy and Found Responsible Party:
Procedures

1. LOST AND FOUND

1.1 To establish guidelines for the Diagnostic Imaging Department in

compliance with Security Management Plan.

1.1.1 Any items found in patient exam or other areas are to

be secured in the following manner:

1.1.1.1 A Lost and Found Form is to be

completed and attached to the item.
1.1.1.2 The item will be placed in the Lost and
Found Box prominently displayed in the
Client Services Office.
1.1.1.3 A valuable item will be given directly to a
Client Services clerk who will lock it in the
safe.
1.1.1.4 Do not keep a lost item and attempt to
contact the patient or patient’s family.
1.1.1.5 The Security Department will be
responsible for logging in all items placed
in the box in Client Services, and
following up to return the item to the
correct individual.
1.1.1.6 If a patient or customer reports a lost item
to an employee of the Diagnostic Imaging
Department, the employee should
contact the Security Department and
make them aware of the situation.
 1.1.1.7 If a Security Officer is not available, a
phone message or email should be made
to the Security Department. Included in
the message should be the name and
telephone number of the person who has
lost an item, the item missing, and your
name and extension number.
1.1.1.8 If someone coming to claim a lost item
approaches an employee, the employee
should contact the Security Officer on
duty at that time.

2. Approvals:

DR. ERVIN T. CASTILLO, MD, MBA-HA

Medical Director
 Hospital Policies and Procedures
Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on In-Patient

Policy and and Out-Patient Flow Chart on Responsible Party:
Procedures Processing X-RAY Examination

IN PATIENT FLOW CHART ON PROCESSING X-RAY EXAMINATION

START

SECURE REQUEST FORM OF

X-RAY FROM ER/WARD

LET PATIENT OR WATCHER

SIGN THE REQUEST

PRESENT REQUEST FORM TO

X-RAY DEPARTMENT

SETTING A SCHEDULE WHEN

TO PERFORM THE
EXAMINATION

LET THE ORDERLY PICK THE

PATIENT ON HIS/HER ROOM

PERFORM X-RAY EXAMINATION

ASK THE RADIOLOGIST FOR THE

RESULT
 ENDORSE RESULT TO THE NURSES
STATION
OUTPATIENT FLOW CHART ON PROCESSING X-RAY
EXAMINATION

START

SECURE REQUEST FORM OF

X-RAY FROM ER/WARD

PAY TO THE CASHIER ALONG

WITH THE REQUISITION FORM

PRESENT PAID REQUEST FORM

TO THE RADIOLOGY
DEPARTMENT

PERFORM X-RAY
EXAMINATION

RELEASING OF RESULTS

Approvals:

DR. ERVIN T. CASTILLO, MD, MBA-HA

Medical Director
 Hospital Policies and Procedures
Mindanao Doctors Hospital and Cancer Center Inc.
National Highway, Osias, Kabacan, North Cotabato

Title RADIOLOGY DEPARTMENT Effectivity Date:

Policy and Procedures on Imaging

Policy and Department Organizational Responsible Party:
Procedures

IMAGING DEPARTMENT ORGANIZATIONAL CHART

MEDICAL DIRECTOR

RADIOLOGIST

CHIEF RADIOLOGIC
TECHNOLOGIST

RADIOLOGIC X-RAY
TECHNOLOGIST TECHNOLOGIST

RADIOLOGIC RADIOLOGIC
TECHNOLOGIST TECHNOLOGIST

RADIOLOGY CLERK

APPROVE BY:

DR. ERVIN T. CASTILLO, MD, MBA-HA

Medical Director