Sop Radiology Dec Final

GDMCH/RD/SOPM-01
Government Dharmapuri Medical College

&
Hospital
Radiodiagnosis Department
Standard Operating Procedures Manual
GDMCH/RD/SOPM-01
RADIO DIAGNOSIS,
GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

GDMCH/RD/SOPM-01
Issue No: 01 Issue Date: 01.06.2022
TABLE OF CONTENTS
S.No Contents Page
1
Amendment Sheet
2
Release Authorization
Control of the manual, Manual authority,
3
Distribution list of manual
4
Manual Awareness Certificate
5
Quality Policy/ Quality Objectives
6
Table of Contents
Scope of services – Radio diagnosis
7
Scope of services – Radio diagnosis
8
9 Scope of services – microbiology

Sample registration & collection
10
11 Sample transport
12 Sample preparation
Sample rejection criteria
13
Sample processing
14
Sample retention
15
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
AMENDMENT SHEET
Guideline for using Amendment Record sheet:
This Standard Operating Procedure Manual belongs to Radio diagnosis Department of

Govt Dharmapuri Medical College And Hospital and Amendments made in manuals/
procedures from time to time will be traced through the above format. Amendment
Record sheet will show the current amendment No. and date. The arrangement of the
Amendment details would be such that the latest amendment (decided by Date) will be
mentioned first followed by the other amendments arranged in reverse chronological
order and the first amendment will be shown as the last item. Whenever the issue
changes for any of the reasons mention above, the amendment record sheet will start
afresh, not indicating the amendments made in the previous issue. The previous issued
document will be stamped as obsolete and retained under the custody of the Head of the
Department.
S.No. Issu Procedure Date of Amendment Reasons Amended Approved

e No Amendment Made For By by
Amendmen
t
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
RELEASE AUTHORIZATION
This departmental process and instruction manual is released under
the authority of
Dr A.ARUMUGAM MBBS DMRD.,

Senior Resident In The Cadre of CCS ,
Department of Radio diagnosis
&
is the property of
RADIO DIAGNOSIS,

DHARMAPURI
Tamil Nadu – 636 701
Signature :
Name&Designation : Dr A.ARUMUGAM MBBS DMRD

Senior Resident In The Cadre of CCS
HOD I/C
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
CONTROL OF THE MANUAL

The holder of the copy of this manual is responsible for maintaining it in good and safe
condition and in a readily identifiable and retrievable manner. The holder of this manual
shall maintain it in current status by inserting latest amendments as and when the
amended versions are received by updating the amendment sheet. Consultant
responsible for issuing the amended copies to copy holder(s) should acknowledge the
same and he/she should return the obsolete copies to the consultant. The manual will be
reviewed once a year and is updated as relevant to hospital policies and procedures.
Review and amendment can happen as corrective actions to non-conformities raised
during the self assessment or assessment audits by NABH.
AUTHORITY OVER CONTROL OF

THIS MANUAL
Preparation & Review of the Manual –
NABH Nodal officer for Radio
diagnosis
Approval of the Manual by – Head of
The procedure manual with original
signatures of the above on the title
page is considered as “Master
Copy”
The Photocopies of the master copy
for distribution are considered
“Controlled Copies”
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
DISTRIBUTION LIST OF MANUAL
S.NO DESIGNATION SIGNATURE

.
1. Dean
2. Medical Superintendent
3. NABH Nodal Officer
4. NABH Quality Manager
5. Professor & Head of Dept of Radio diagnosis
6. Senior Resident Dept of Radio diagnosis
7. Radiation Safety Officer RSO
8. Chief X Ray Technician for Radio diagnosis
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
DISTRIBUTION LIST OF MANUAL

S.No Participant Post Signature
1 R.Mariappan CXRT
2 P.Pari Radiographer
3 N.Baskaran Radiographer
4 A.Benjamin Radiographer
5 K.Sivasankari Radiographer
6 M.Raghavendran Radiographer
7 N.Bhagyalakshmi Radiographer
8 Velmurugan Radiographer
9 G.Raja Radiographer
10 Elumalai Radiographer(CT-SCAN)
11 Lakshmipathy Radiographer(CT-SCAN)
12 Suresh Kumar Radiographer(CT-SCAN)
13 Ragul Radiographer(CT-SCAN)
14 Vasanth Radiographer(CT-SCAN)
15 Lokesh Radiographer(CT-SCAN)
16 Rajesh Radiographer(CT-SCAN)
17 KALAIVANI Radiographer(CT-SCAN)
STANDAR
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
INDEX
S. No. Title Pages
1 Radio diagnosis Policy 8-23
1 Radio diagnosis SOPs 24-54
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
RADIO DIAGNOSIS DEPARTMENT POLICY

DOCUMENT
a. Department defines the department’s Vision, Mission and Values.
Vision-
mission-
b. Department chooses leaders and establishes hierarchy in the department.
Name Of The Post Name Of The Staff

Professor And Hod
Associate Professor
Assistant Professor Dr .S.Sangeetha Mbbs,Dmrd
Senior Residents Dr .Arumugam Mbbs,Dmrd
Dr.K.Thanushkodi Mbbs,Dmrd
Dr S.Sangeetha Mbbs ,Dmrd
Chief X Ray Technician
Radiographers
Ct Technicians
Data Entry Operators
Department is aware of current applicable laws and ensures that the department adheres
to them.the department complies wit PCPNDT ,AERB norms
c. Department ensures acquisition of all relevant licenses and their updation.

updated pcpndt ,AERB licences are available to all relevant equipments
d. Department ensures ethical practice in all patient services that the department
provides.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
1. The Scope of Medical Imaging Services being provided by our department are clearly defined and prominently
displayed.
GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL DHARMAPURI

DEPARTMENT OF RADIO DIAGNOSIS-கதிரியல் துறை
X RAY UNIT SCOPE OF SERVICES -எக்ஸ்-கதிர் பிரிவு அளிக்கப்படும் சேவைகள்
ROUTINE X RAY STUDIES (PLAIN) -வழக்கமான எக்ஸ்-கதிர் பரிசோதனைகள்
S.N எக்ஸ்-கதிர் பரிசோதனை S.N எக்ஸ்-கதிர் பரிசோதனை
O O
1 SKULL AP/LAT 16 FOREARM [AP/LAT]
2 Skull TOWNE VIEW 17 WRIST [AP/OBLIQUE/SCAPOID VIEW/CARPAL TUNNEL VIEW
3 SKULL MASTOID VIEW 18 HAND [AP/OBLIQUE/LATERAL]
4 SKULL MANDIBLE LATERAL OBLIQUE 19 HIP JOINT [AP/TRACTION AND INTERNAL ROTATION]
5 SKULL PARA NASAL SINUSES 20 THIGH [AP/LAT]
6 SUBMENTOVERTEX VIEW 21 PELVIS [AP/FROG LEG VIEW/TRACTION AND INTERNAL ROTATION]
7 NASOPHARYNX 22 SHOULDER [AP/Y VIEW/WEIGHT BEARING STRESS VIEW]
8 C.SPINE AP/LAT/FLEXION/EXTENSION 23 SHOULDER [AP/Y VIEW/WEIGHT BEARING STRESS VIEW]
9 D.L. SPINE AP/LAT/FLEXION/EXTENSION 24 KNEE JOINT [AP/LAT/SKYLINE VIEW/VARUS STRESS VIEW]
10 L.S.SPINE AP/LAT FLEXION/EXTENSION 25 ANKLE JOINT [AP/LAT/MORTIS VIEW ]
11 CHEST [AP/PA/LAT/DECUBITUS 26 CALCANIUM
VIEW/LORDOTIC VIEW
12 ABDOMEN [AP/PA/ERECT/KUB/LATERAL] 27 FOOT [AP/OBLIQUE]
13 PELVIS [AP/FROG LEG VIEW/TRACTION AND 28 KNEE JOINT [AP/LAT/SKYLINE VIEW/VARUS STRESS VIEW]
INTERNAL ROTATION]
14 SHOULDER [AP/Y VIEW/WEIGHT BEARING 29 ANKLE JOINT [AP/LAT/MORTIS VIEW ]
STRESS VIEW]
15 ARM WITH ELBOW [AP/LAT]
X RAY CONTRAST STUDIES -சிறப்பு மருந்து எக்ஸ்-கதிர் பரிசோதனைகள்
1 BARIUN SWALLOW 4 INTRAVENOUS UROGRAM
2 BARIUM MEAL 5 BARIUM ENEMA
3 BARIUM MEAL FOLLOW THROUGH 6 CYSTOGRAM
SERVICES NOT AVAILABLE அளிக்கப்படாத சேவைகள்
1 ORAL PANTOMOGRAM 2 CONVENTIONAL ANGIOGRAM

அரசு தர்மபுரி மருத்துவ கல்லூரி மருத்துவமனை தர்மபுரி
ULTRASOUND UNIT SCOPE OF SERVICES -மீயொலிபிரிவு அளிக்கப்படும் சேவைகள்
S.N ROUTINE USG STUDY வழக்கமான USG SPECIAL STUDIES சிறப்பு மீயொலி பரிசோதனைகள்
O மீயொலி பரிசோதனைகள்
1 ABDOMEN & PELVIS / வயிறு அடி வயிறு 1 VENOUS DOPPLER UPPER LIMB /LOWER LIMB தமனி டாப்ளர்
2 PELVIS அடி வயிறு 2 ARTERIAL DOPPLER UPPER LIMB / LOWER LIMB தமனி டாப்ளர்
3 BREAST மார்பகம் 3 PORTAL VEIN DOPPLER போர்டல் சிரா நரம்பு டாப்ளர்
4 THYROID AND NECK தைராய்டு கழுத்து 4 CAROTID DOPPLER கரோடிட் தமனி டாப்ளர்
5 SCROTUM விதைப்பை 5 RENAL DOPPLER விதைப்பை டாப்ளர்
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
6 CRANIUM மூளை 6 SCROTUM DOPPLER டாப்ளர்

7 ANC SCAN EARLY/NT/ ANOMALY/ GROWTH 7 AORTAL DOPPLER பெருநாடி தமனிடாப்ளர்
SCAN S கர்ப்ப காலபரிசோதனைகள்
8 SMALL PARTS சிறிய பாகங்கள்
INTERVENTIONAL USG SERVICES NOT AVAILABLE அளிக்கப்படாத சேவைகள்
1 USG GIUDED LIVER ABCESS DRAINAGE/ PIGTAIL CONTRAST ULTRASOUND STUDY
CATHER INSERTION
2 USG GUIDED FNAC OF THYROID NODULES,
LYMPHADENOPATHY,MASS

SCOPE OF SERVICES CT SCAN UNIT சி டி ஸ்கேன் பிரிவு அளிக்கப்படும் சேவைகள்
CT SCAN ROUTINE STUDIES (PLAIN AND CONTRAST )சி டி ஸ்கேன் வழக்கமான பரிசோதனைகள்
S.N STUDY S.N STUDY
O O
1 BRAIN PLAIN AND IV 16 HIP PLAIN AND IV
2 FACIAL BINE 17 KNEE PLAIN AND IV
3 TEMPORAL BONE 18 ANKLE PLAIN AND IV
4 ORBIT PLAIN AND IV 19 FOOT PLAIN AND IV
5 NECK PLAIN AND IV 20 PNS PLAIN AND IV
6 CERVICAL SPINE PLAIN AND IV 21 DORSO-LUMBAR SPINE PLAIN AND IV
7 DORSAL SPINE PLAIN AND IV 22 THIGH PLAIN AND IV
8 LUMBAR SPINE PLAIN AND IV 23 LEG PLAIN AND IV
9 CHEST PLAIN AND IV 24 HRCT-CHEST
10 ABDOMEN PLAIN AND IV ORAL RECTAL 25 KUB PLAIN AND IV
11 SHOULDER PLAIN AND IV 26 ARM PLAIN AND IV
12 ELBOW PLAIN AND IV 27 FOREARM PLAIN AND IV
13 WRIST PLAIN AND IV
14 HAND PLAIN AND IV
15 PELVIS PLAIN AND IV
CT SPECIAL CONTRAST STUDIES சிறப்பு சி டி ஸ்கேன் SERVICES NOT AVAILABLE அளிக்கப்படாத சேவைகள்
பரிசோதனைகள்
1 PULMONARY ANGIOGRAM 1 CT GUIDED BIOPSY
2 UPPER LIMP ANGIOGRAM
3 LOWER LIMP ANGIOGRAM
4 AORTOGRAM
5 ABDOMINAL ANGIOGRAM
6 CAROTID ANGIOGRAM

SCOPE OF SERVICES MRI UNIT எம் ஆர் ஐ ஸ்கேன் பிரிவு அளிக்கப்படும் சேவைகள்
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
MRI STUDIES (PLAIN AND CONTRAST )எம் ஆர் ஐ ஸ்கேன் வழக்கமான பரிசோதனைகள்
S.N STUDY
O
1 BRAIN PLAIN AND IV 6 PELVIS PLAIN AND IV
2 CERVICAL SPINE PLAIN AND IV 7 FISTULOGRAM PLAIN AND CONTRAST
3 DORSAL SPINE PLAIN AND IV 8 KNEE PLAIN AND IV
4 LUMBAR SPINE PLAIN AND IV 9 SHOULDER PLAIN AND IV
5 ABDOMEN PLAIN AND CONTRAST
S.N SPECIAL MRI STUDY சிறப்பு எம் ஆர் ஐ SERVICES NOT AVAILABLE அளிக்கப்படாத சேவைகள்
O ஸ்கேன் பரிசோதனைகள்
1 MRA AND MRV PLAIN AND CONTRAST CARDIAC MRI
2 MR SPECTOSCOPY
3 MRCP
2. PATIENT REGISTRATION POLICY
a. Patients coming to the department for various imaging services are guided to appropriate reception counter x ray / usg /
ct / mri by help teams
b. Staff in the reception counter receives the patient and thoroughly check the requisition.
c. each patient is identified by his/her name, age sex and IP / OP number.

only fully filled requisitions containing patient name age, sex , IP/OP no ,department ward, clinical impression , referring
doctors name,medical council registration no with seal are accepted.
d. After verification of requisition the patient is registered and unique identification number is created for the each
study .then patients are guided to appropriate examination room
e. All attempts are made to ensure that the unique identification number is maintained for each study of patient
and is available for review and subsequent visits.
f. all information about the procedure requested, the relevant clinical and lab details and information about prior
imaging is captured and is readily available to all the staff involved in patient care for verification prior to the
performing the procedure and reporting team.
g. The staff in the reception counter are trained to ensure that the imaging is appropriate for the patient and
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
the clinical indication.

h. emergency and urgent studies are noted from the requisitions as they are marked by the requesting physician
and they are given prioritization in scheduling and reporting.
3 PATIENT INFORMATION POLICY
a. Patients and families are informed of their rights and responsibilities in a format and language that they can
understand and it is displayed .
b. The information about specific procedure is explained to patients and accompanying persons in
relevant format and language including the local language.
c. The expected cost is informed prior to imaging
d. The privacy and dignity of the patient is preserved without any discrimination.
e. Confidentiality of patient information will be maintained.
f. Patient and family have a right to seek an additional opinion.
4 INFORMED CONSENT POLICIES
a. the list of situations where informed consent is required is available

informed consent is must for all contrast procedures and all interventional radiology procedures
b. content of Informed consent includes information regarding the procedure, it’s risks, benefits, in a language
that they can understand.
c. The consent should be signed by either patient or by his/her attenders when patient is incapable of
independent decision making.
d. Informed consent is taken by the person performing the procedure or by a staff member of his team.
5 EMERGENCY STUDT POLICIES

a. Emergency studies are marked by the referring physician and are identified by department staff in the reception
counter and labeled as emergency
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
b. Emergency studies are prioritized during imaging and reporting.
c. medico-legal cases are documented and labeled properly.
d. all staff are oriented towards emergency cases
PATIENT TRANSPORT POLICY
a. Responsibility of safe and timely transportation of patient to the radio diagnosis department and from radio
diagnosis back to department lies with the referring department,.
b. Responsibility of safe and timely transportation of patient within the department and to emergency department
in case of emergencies lies with radio diagnosis department.
c. Adequate number of wheel chairs and stretchers are available with the department for safe transport of
patients within the department
6 POLICY FOR EMERGENCY INTERVENTION IN CASE OF LIFE THREATENING EVENT
a. Staff providing direct patient care are trained and periodically updated in emergency life support and cardio-
pulmonary resuscitation.
b. An appropriately equipped resuscitation tray is maintained.
c. The events during any emergency life support and cardiopulmonary resuscitation are provided.
d. Patients are transferred to an appropriate acute care facility when required.patients who needs acute care are
transported to ED dept with 10 minutes
7 SEDATION AND ANESTHESIA POLICY
a. Informed consent for administration of anaesthesia and moderate sedation is obtained

b. Competent and trained persons perform anaesthesia and sedation.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
c. Conscious sedation by injection midazolam is used for needy patient need for sedation is decided by radiologist
dose chart is available.
d. The patient is appropriately monitored on predefined parameters during and after the procedure till the
discharge.
e. The type of anaesthesia and anaesthetic medications used are documented in the patient record.
f. Adverse Sedation/anaesthesia events are recorded and monitored.
7 IMAGE ACQURING AND INTERPRETATION POLICY
a. Appropriately qualified and trained personnel perform the imaging studies.
b. Qualification for l the technicians - CRA /DRDT/BSC radiology course in a govt recognized instituon.
c. Qualification for radiogosists - diploma or degree from NMC recognized medical college
d. The protocols for image acquisition for all examination are developed based on current best practices,
documented and are available at the place of work.
e. The protocols are appropriate for the specific age, sex; clinical indications, anatomical part and modality.
f. The protocol implementation is monitored, and protocol deviations are documented and
analysed to ensure appropriateness.
g. The protocols include appropriate post processing, and quantification as appropriate for the clinical indication.
h. The protocols for image acquisition for all examination are reviewed at a defined periodicity for improvement
and adaptation of the current best practices.
i. T o prevent events like a wrong site, wrong patient and wrong procedure.patients are identified by two factors
IP / OP number , name with age and sex.then imaging study is confirmed from the requisition by reception
staff , confirmed by technicians and radiologist
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
j. Patients are appropriately monitored during and after the procedure.
k. The quality of diagnostic images and completeness of the procedures is monitored through a
documented process.
8 INTERVENTIONAL STUDY POLICY
a. Adequately qualified and trained staff members perform and assist the procedures.
b. The protocols for all diagnostic and therapeutic interventional procedures are developed and documented.
c. Interventional procedure patients have a pre procedural assessment and a provisional diagnosis documented
prior to procedure.
d. An informed consent is obtained by a member of the Team performing the procedure prior to the
procedure and same is documented.
e. Radiation safety procedures are followed.
f. Infection control practices are followed.
g. Appropriate facilities and equipment/ appliances/ instrumentation are available in the procedure area.
h. Appropriate sedation/anaesthesia, clinical and emergency support is available before,

during and after the procedure.
i. A procedure note is documented prior to transfer out of patient from the facility.
j. The outcomes of diagnostic and therapeutic interventional procedures are monitored.
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GDMCH/RD/SOPM-01
9 REPORTING POLICY
a. Appropriately qualified and trained personnel interpret the imaging studies on display systems appropriate
for the studies and modalities.
b. Imaging report t is provided to the patients for each procedure.
c. Results are reported in a standardized manner and the best practices.
d. The document contains the patient’s name, unique identification number, and date of the procedure.
e. The document contain Diagnosis or Differential diagnosis, the procedure performed.
f. The report ensures that the current Clinical Indication for the Imaging study is addressed.
g. The document contains advice for any other further investigation, follow-up imaging advice, and other
instructions as appropriate in an understandable manner.
h. There is a defined Standard Operating Procedure to address recall / amendment of reports when required.
10 CRITICAL FINDING REPORT POLICY

a. There is a documented policy on routine, urgent and critical Imaging reports with a defined Turn Around
time for each of them.
b. A list of conditions requiring critical and urgent communication is defined.
c. The reports are communicated to the patient and/or referrer within the appropriately defined
timeframe based on the clinical indication and urgency.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
11 TURN AROUND TIME POLICY

WAITING AND TURN AROUND TIME FOR X RAYS STUDIES எக்ஸ்-கதிர் பரிசோதனைகள் காத்திருக்கும் மற்றும் படம்
,முடிவுகள் வழங்கும் நேரம்
NAME OF THE STUDY WAITING TIME TAT FOR FILMS AND REPORTS/ படம் மற்றும் முடிவுகள் வழங்கும்
ரிசோதனையின் பெயர் காத்திருக்கும் நேரம்
நேரம்
FILM AND REPORTS FOR STUDIES DONE FROM 1 PM TO 8 PM
FOR STUDIES DONE FILM/ படம் REPORT / முடிவுகள்
FROM 8 AM TO 1 PM
படம் , முடிவுகள்
LL BODY PARTS ROUTINE 15 MINUTES 30 MINUTES 30 MINUTES NEXT DAY 9 AM/மறுநாள்
LAIN STUDY /சாதாரண 15 நிமிடங்கள் 30 நிமிடங்கள் 30 நிமிடங்கள் காலை 9 மணி
ரிசோதனைகள்
LL CONTRAST STUDIES AND 30 MINUTES 60 MINUTES 60 MINUTES NEXT DAY 9 AM மறுநாள்
PECIAL CONTRAST STUDIES/ 30 நிமிடங்கள் 60 நிமிடங்கள் 60 நிமிடங்கள் காலை 9 மணி
மருந்து செலுத்தி
எடுக்கப்படும் சிறப்பு
ரிசோதனைகள்
MERGENCY CASES/அவசர 1O MINUTES/ 15 MINUTES 15 MINUTES 20 MINUTES
ரிசோதனைகள் 10 நிமிடங்கள் 15 நிமிடங்கள் 15 நிமிடங்கள் 20 நிமிடங்கள் THROUGH
TELEMEDICINE

WAITING AND TURN AROUND TIME FOR MRI SCAN STUDIES எம் ஆர் ஐ ஸ்கேன் பரிசோதனைகள்
காத்திருக்கும் மற்றும் படம் முடிவுகள் வழங்கும் நேரம்
E OF THE STUDY WAITING TIME TAT FOR FILMS AND REPORTS/ படம் மற்றும் முடிவுகள்
சோதனையின் காத்திருக்கும் வழங்கும் நேரம்
யர் நேரம்
FILM AND FOR STUDIES DONE FROM 1 PM TO 8 PM
REPORTS FOR FILM/ படம் REPORT / முடிவுகள்
STUDIES DONE
FROM 8 AM TO 1
PM படம் ,
முடிவுகள்
ODY PARTS ROUTINE 40 MINUTES 80 MINUTES 60 MINUTES NEXT DAY 10 AM/
N 40 நிமிடங்கள் 80 நிமிடங்கள் 60 நிமிடங்கள் மறுநாள் காலை 10
Y /சாதாரண மணி
சோதனைகள்
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
ONTRAST STUDIES 60 MINUTES 120 MINUTES 90 MINUTES NEXT DAY 10 AM/

SPECIAL CONTRAST 60 நிமிடங்கள் 120 நிமிடங்கள் 90 நிமிடங்கள் மறுநாள் காலை 10
IES/ மருந்து மணி
லுத்தி
க்கப்படும் சிறப்பு
RGENCY 20 MINUTES/ 40 MINUTES 30 MINUTES 40 MINUTES
S/அவசர 20 நிமிடங்கள் 40 நிமிடங்கள் 30 நிமிடங்கள் 40 நிமிடங்கள்
சோதனைகள் THROUGH TELEMEDICINE

WAITING AND TURN AROUND TIME FOR ULTRASOUND SCAN STUDIES மீயொலி
ஸ்கேன்பரிசோதனைகள் காத்திருக்கும் மற்றும் முடிவுகள் வழங்கும் நேரம்
E OF THE STUDY WAITING TIME காத்திருக்கும் TAT FOR REPORTS/

சோதனையின் பெயர் நேரம் முடிவுகள் வழங்கும்
நேரம்
ODY PARTS ROUTINE PLAIN 20 MINUTES 40 MINUTES

Y /சாதாரண 20 நிமிடங்கள் 40 நிமிடங்கள்
RGENCY CASES/அவசர 10 MINUTES/ 20 MINUTES
சோதனைகள் 10 நிமிடங்கள் 20 நிமிடங்கள்
TELE RADIOLOGY SERVICES POLICY
a. All clinical, lab and prior imaging information is available to the tele radiology services provider.
b. Appropriately qualified and trained personnel interpret the imaging studies.
c. Appropriate equipment is used for acquisition, communication, display, and storage of images.
d. Results are reported in a standardized manner consistent with the departmental standards.
e. There is a defined Standard Operating Procedure to address recall / amendment of reports when
required.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
SAFETY PROGRAM POLICY

a. The radiation-safety program is documented and developed by the radiation safety committee of the
department and implements the principals of ALARA.
b. This program is implemented and overseen by an appropriately designated Radiation Safety Officer and
is aligned with the department's safety program.
c. Radiation signage are prominently displayed in all appropriate locations.
d. Patients are appropriately screened for safety / risk prior to undergoing an imaging on a particular
modality.
e. Staff personnel and patients are provided with appropriate radiation protection devices.
f. Personal radiation monitoring devices are provided to all the Radiation workers.
g. The safety program also addresses the risk associated with MRI.
a. atient-safety devices & infrastructure are installed across the department and inspected periodically.
b. Inspection reports are documented and corrective and preventive measures are undertaken.
a. Facilities are appropriate to the scope of services of the department.
b. Up-to-date drawings are maintained which detail the site layout, floor plans and fire-escape routes.
c. There is appropriate internal and external sign postings in the department in a language understood by
patient, families and community.
d. The provision of space shall be in accordance with the current good practices (Indian or International
Standards) and directives from government agencies.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
e. electricity is available round the clock.
f. Alternate sources for electricity are provided as backup for any failure / shortage especially for the
Equipment and the department regularly tests these alternate sources.
g. There is a maintenance plan for electrical systems.
h. There are designated individuals (with appropriate equipment) responsible for the maintenance of all the
facilities.
i. Maintenance staff is appropriately qualified, trained and contactable round the clock for emergency
repairs.
j. There is a maintenance plan for facility and furniture.
k. Response times are monitored from reporting to inspection and implementation of corrective actions.
l. The department takes initiatives towards an energy efficient and environmental friendly facility.
a. The department has plans and provisions for early detection, abatement and containment of fire and
non-fire emergencies.
b. The department has a documented safe-exit plan in case of fire and non-fire emergencies.
c. Staff is trained for their role in case of such emergencies.
d. Mock drills are held at least twice in a year.
e. There is a maintenance plan for fire-related equipment & infrastructure.
EQUIPMENT POLICY
a. The department plans for equipment in accordance with its services and strategic plan.
b. Equipment are inventoried and proper equipment history and logs are maintained.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
c. The installation of the equipment is safe and commensurate with the applicable laws.
d. The operation of the equipment is safe and compliant with the applicable laws.
e. Appropriate Calibration and Quality Assurance of the equipment is performed at a defined periodicity.
f. There is a documented operational and maintenance (preventive and breakdown) plan for All Equipment.
g. Equipment cleaning and disinfection adheres to the transmission based

precautions at all times.
h. The department identifies and plans for obsolescence, condemning and decommissioning of the
equipment.
i. Qualified and trained personnel inspect, test and maintain equipment and utility systems.
MANAGEMENT OF MEDICATION POLICY

a. There is a documented policy and procedure for procurement and stocking of contrast media, and other
medications commensurate with the scope of services.
b. Medicinees are stored in a clean, safe and secure environment.
c. Sound inventory control practices guide storage of the medications.
d. There is a documented policy for usage of multidose packaging, and their discard.
a. Contrast media and other Medications are handled and administered by those who are permitted and trained to do so.
b. drug reactions, and other adverse drug events are monitored and managed .
c. the patients at a high risk for adverse events following contrast injections are identified before administration
of contrast .
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
d. Documented procedures guide monitoring of patients during and after administration of

contrast media and other medication.
TRAINING POLICY
a. Every staff member is made aware through induction training of department’s wide policies and
procedures.
b. A documented training and development policy exists for the staff.
c. Retraining occurs at a defined periodicity; and also when job responsibility changes and/or new
equipment is introduced.
d. Staff are trained on the risks as applicable to the department's environment at a defined periodicity.
e. Staff are also trained on occupational safety aspects.
There is a system of periodic review to ensure that feedback is utilized to improve services.
INFORMATION POLICY
a. The Information and Information-Technology needs of the department are identified.
b. Ct csan ,mri images are transferred to reporting computer system immediately.

there are two systems for ct reporting and two systems for mri reporting
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
x ray images are transferred to one system in the department and one system in ED department for
viewing and reporting. Good quality soft wares are installed in the above system with all modern facilities
for reporting
c. Tele radiology facility is utilized , in a safe and secure manner.

entire ct scan and mri images are immediately transferred to central mediff server once scanning is
completed .the quality of images are maintained for tele reporting. Tele reporting soft ware is provided
with all the functions like zoom, measurement ,3D reconstruction
d. The department contributes to external databases in accordance with the law and regulations. (AERB, PC-
PNDT, NABH and others).
e. The department has an effective process for document control.
f. storing and retrieving data is done properly.
a. Every imaging record has a unique identifier which is maintained for each patient and is available on all
subsequent visits
b. Department policy identifies those authorized to make entries in imaging record.
c. The mandatory contents of imaging record are identified and documented.

they are patient name ,age,sex, ID no , date ,study detail , diagnosis with findings.
RECORD MAINTANECE POLICY
a. Patient records, data and information are maintained with confidentiality, security and integrity
b. Patient data/ record are safeguarded against loss, destruction and tampering.
c. Staff are trained respond to patients / physicians and other public agencies requests for access to
information in the medical record in accordance with the local and national law.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
SOP for Radiology
Objective:
To ensure consistently safe, effective, efficient, appropriate, & timely imaging diagnostic services
to each patient visiting the hospital.
Purpose: Smooth running of radiology department to ensure uninterrupted patient service
Scope : Entire radiology department
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
Sl.No. Activity/Description Responsibility Ref

Doc/
Record
1. Statutory compliance
1.1 HOD & RSO shall be responsible for compliance to AERB registration pertaining RSO & PNDT In
to equipment using X rays in the department charge
a) eLORA registration/licensing of the institution/department, RSO & all Bio medical
Egineer
equipment shall be done & maintained
b) Periodic QA of equipments& premises (as per AERB guidelines) will be done
through the authorized agency and submitted to AERB.
c) Radiation workers will be identified & TLD badge monitoring shall be done
for them as per AERB guidelines. Dept.
d) Periodic health check including blood cell count & general physical Head/Hospital
examination shall be conducted & recorded for all radiation workers as per RSO
AERB guidelines.
e) Availability, maintenance, QA of all radiation barriers (lead aprons, goggles,
gonadal shields, lead curtains)
f) Education, training & monitoring regarding radiation safety practices shall
be done by RSO.
g) These activities will extend C arms in OT etc.
1.2 HoD shall be responsible for compliance to PCPNDT regulations pertaining to HoD
US//Doppler in the in the department.
a) PCPNDT registration of the institute/department/ equipment &
personnel handling these equipment shall be done & maintained.
b) Daily & monthly reporting on relevant formats to competent authority shall
be done.
c) All mandated relevant displays and signage
shall be maintained as per PCPNDT guidelines
2. Signages RSO/ PNDT

Nodal Officer
2.1 Statutory Signages: All safety & statutory signangs & displays as per AERB & HOD
PCPNDT ,MRI guidelines s shall be placed inside/outside all equipment rooms (as
per guidelines).
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
The displays shall be in languages & formats as per guidelines.

For PCPNDT, copy of registration certificates & display regarding non declaration
of sex of fetus in prescribed format, shall be done in every room where USG/
ECHO equipment is installed.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
2.2 Informative signage – At the minimum following information signages shall be

displayed(using appropriate languages, font sizes & format) at eye level. The
signage shall be static & permanent Services provided with room numbers.
a) Timings
b) Directions
c) Safety related education signages X Ray rooms – as (2.1)&
(2.3) US/Echo – as above (2.1)
2.3 Safety signage – Radiation safety
Radiations safety signages: Safety signage should be as recommended by AERB
including restrictions of patient/attendant entry, hazard lights and pictorial
signages appropriate for radiology services (Example picture given)
outside of the radiationrooms.
At the minimum, following signage shall be used outside all rooms where X ray,
fluro, CT equipments are installed.
and
MRI safety : Pictorial signages regarding absolute contra indications to MRI. MRI
Pictorial display regarding absolute contraindications to MRI & warnings
regarding hazards associated with metallic
objects in MRI room
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GDMCH/RD/SOPM-01
2.4 Display of telephone numbers to be contacted for respective safety codes e.g., HOD
code blue/code red/code violet in all rooms where I/V contrast is
given.
3 Equipment HOD/Senior
Technician In
charge
procurement & installation of equipments shall be as per government rules.
Operation of equipment shall be by appropriate personnel qualified & trained for
the specific jobs
Daily calibration shall be performed by the operator technician at the time of
switching on in the morning.
Daily cleaning of cleanable parts of the equipment shall be ensured by the
operator at the time of switching off.
Periodic maintenance (preventive) & periodic calibration & QA shall be done by
the service engineers from the AMC/CMC provider. The records shall be
maintained by the Technical In charge.
Department shall maintain an equipment log book with information regarding all
equipment under the following categories:
a) Main Imaging Equipment - e.g., X ray, US, CT, MRI machines,
injectors,
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
b) Each unit shall be identifiable with a

traceability number as reflected on the
unit & in the log book.
All equipment shall have dedicated history sheet

where details regarding purchase, operation,
functionality, maintenance & breakdown shall be
maintained.
Inventory of all accessory and ancillary
equipment.
4 Staff/Personnel HOD
Availability of appropriately qualified and trained
staffs as per the scope of services.
Availability, job descriptions, rosters, leave records
etc shall be ensured as per government
guidelines/rules.
Appropriate numbers and mix of the following staffs
shall be available to provide patients services for
routine & emergency imaging.
a) Radiologists – Consultants & Resident
doctors
b) Technical Staff
c) Nursing staff
d) Ancillary staff
e) Data Entry Operator
Nursing staff may be required in the department,
where contrast injections/sedation/invasive
procedures are being carried out.
All Staff shall be trained on respective core activity &
work under supervision during induction period (1
week).
Training of all staff shall also be periodically done for
the following at the minimum:
i. BLS
ii. BMW waste rules
iii. Radiation safety
iv. Infection control practices
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
5 Materials HOD/Technician I/C of store

5.1 Consumables and non consumable materials
required in the department shall be listed in a
log book e.g., -
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
Consumables – Films, contrast media, signages,

saline, injectors etc.
Non Consumables – Protective devices (lead
aprons), cassettes, screens, grids etc
The procurement shall be as per government
rules.
Storage shall be in safe place with appropriate
environment control.
Appropriate stock & inventory shall be maintained to
prevent stock outs, overstocking of slow moving
items & expiry of items without utilization. Good
inventory practices like Vital, Essential, Desirable
(VED), First Expiry First Out (FEFO), ABC* etc shall be
used.
Record of issuing & consumption shall be
maintained & periodically sent to appropriate
authority.
All instances of stock outs/non-moving
stocks/expired stock shall be logged & analysed. It
shall be reported to appropriate authority
&Corrective and Preventive Action
(CAPA) shall be suggested.
6 Drugs & Medication
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
Medication shall include the following: Staff nurse/Technician

a) Contrast media – I/V – nonionic
b) Contrast media – oral
c) MR contrast media – I/V
d) Medication for resuscitation in crash cart/
Emergency Tray
Procurement shall be as per government rules

Storage shall be in safe place with appropriate
environment control.
Appropriate stock & inventory shall be
maintained to prevent, stock outs, overstocking
of slow moving items & expiry of items without
utilization. Good inventory practices like Vital,
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
Essential, Desirable (VED), First Expiry First Out

(FEFO), ABC* etc shall be used.
Record of issuing & consumption shall be
maintained & periodically sent to appropriate
authority.
All instances of stock outs/non-moving
stocks/expired stock shall be logged & analysed. It
shall be reported to appropriate authority &
CAPA shall be suggested.
7 Patient workflow protocol
Arrival of patient in radiology department: Deptt. Staff/ Technician
A central reception/help desk will
register/schedule the patient for imaging as per the
request form.
Transport of patient from OPD/ IPD shall be the
responsibility of the sender department.
One trolley & wheel chair shall be available in the
department to shift a critical patient to ICU/ward, in
case of an adverse event.
Central reception/help desk shall be responsible
for providing the following information the to the
patients –
a) Date & time of imaging
b) Preparation like NPO, full bladder etc.
c) List of items like towel/water bottle etc to
be brought.
Any patient coming for imaging requiring
contrast injection/sedation/intervention
shall be instructed to be accompanied by
a responsible adult/next of kin.
a) Case of queries regarding routine
medication shall be addressed
by/referred to available
radiologist/doctor in the department.
b) Method and time for collection of report
8 Appropriateness/justification: Radiologist
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
All imaging request forms will be duly filled by the

referring clinician, with appropriate indication &
clinical details, details of previous imaging,
provisional diagnosis, current clinical questions (if
relevant)
These details shall be verified by a radiologists
before scheduling the study.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
Current best practices, availability of equipment and

patient safety shall be kept in mind while choosing
the appropriate imaging for a particular clinical
situation.
In case the imaging request is found
unjustified/unsafe/unavailable, further clarification
shall be sought from the referring doctor before
accepting it.
The above shall be re-verified on the day of imaging
by the radiologist on duty at
respective imaging stations.
9 Scheduling
Scheduling shall be done on first come first
scheduled basis taking into account the
capability of the imaging services.
Priority slots shall be kept for Emergent and Urgent
studies,Indoor patients, Intensive care patients.
Pediatric patients, senior citizens, other vulnerable
patients, and patients on certain medication (e.g.,
Diabetics) shall be prioritized
on the day of study by the operator in-charge.
10 Patient Information Staff nurse/technician

Instructions regarding NPO/ Full Bladder etc.
Accompanying person shall be given in writing, at the
time of scheduling
All the details of the procedure will be explained to
the patient by the staff nurse or technician.
Prior to imaging radiologist shall confirm that
informed consent has been taken.
Information about report collection shall be given at
the time of imaging. Help desk reception also shall be
empowered to provide the information.
Follow up imaging advice shall be provided by the
radiologist verbally/documented in the report.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
11 Informed Consent Sister/Technician

11.1 Where there is contrast
injection/sedation/invasive procedure, a
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GDMCH/RD/SOPM-01
formal Informed consent will be documented.

The Consent will document the indications, benefits,
risks and possible alternatives to the proposed
procedure.
It will be signed and dated by the Radiologist,
Patient/guardian and an impartial witness.
Pre entry risk assessment checklist can be included in
the consent format.
12 Pre-entry safety check/risk assessment:

For X-ray/plain CT , last menstrual period (LMP) shall
be ascertained, and documented, wherever
appropriate to ensure that unnecessary radiation
exposure is not given to pregnant women.
For contrast injection, a check list containing history
of allergy, HT, DM, renal disease, cardiac disease,
asthma, must be checked & documented; preferably
as a part of consent. Recent blood urea ,Serum
creatinine levels shall be documented to screen for
renal dysfunction.
For MRI a checklist containing risk of pace maker,
magnetic material i.e., any operative iatrogenic
implants (cochlea implant, orthopedic implant,
aneurysm clip etc) must be checked &
documented.
For invasive/intervention procedures INR must be
checked & documented in addition to risk of
contrast, as part of consent.
Separate consent shall be taken for sedation.
13 Patient Identification
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
Correct patient must be identified for correct Technician/Radiologist/

procedure at the time of performing the Nurse
procedure, compiling the report and during
dispatch of report. At least two identifiers shall be
used to identify correct patient, one of which shall
be HOSPITAL OP / IP number.
At the time of imaging , correct patient for correct
imaging of correct side/site shall be ensured by
the technician/radiologist performing the
imaging. Radiologist/technician
All images will be appropriately labeled for
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
patient ID, side marker & date of examination.

At the time of compiling the report, patient ID shall
be verified by the radiologist on the envelope,
request form, imaging films & reports.
At the time of report dispatch, the
technician/dispatch desk person shall ensure
correct report for correct patient by using at
least 2 identifiers.
14 Patient preparation:
Removal of metallic articles, change of Nurse/technician
clothing should be done wherever required.
For ultrasound, change of clothing, filling or
emptying of bladder wherever required.
For CT, change of clothing, removal of metallic
articles wherever required.
For MRI, change of clothing, removal of
metallic, magnetizable articles
Oral contrast water/air, rectal
contrast/water/air, IV line wherever
Appropriate
15 Performance of the procedure:
Procedure for taking plain X ray

a) For most x-ray examinations(except x-ray
of abdomen& spine) no special
preparation is required.
b) As with most other imaging procedures,
jewelry and other metallic articles should
be removed and handed over to the
accompanying person.
c) Patient is appropriately positioned and
asked to hold breath/ be still while film is
exposed.
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GDMCH/RD/SOPM-01
Performing Barium studies Technician/Radiologist

a) NPO
b)Preparation as advised at the time of
booking depending on area to be
examined.
c) Change of clothes and removal of metallic
articles/jewelry.
d) Administration of barium suspension as
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GDMCH/RD/SOPM-01
appropriate to examination.
e) Patient appropriately positioned & images
taken, keeping ALARA principle in mind.
Performing Urographic examinations a), b) Technician/Radiologist/
& c) as above. Reporting Nurse
d) informed consent as above of no.11
e) IV line cannulation for injection of
appropriate amount of contrast.
f) Patient appropriately positioned & images
taken, keeping ALARA principle in mind.
15.4 Performing USG/Doppler Radiologist/Nurse

a) Patient arrives as scheduled with full
bladder for pelvic area and NPO for
abdominal examination.
b) Radiologist performs the scan using
appropriate transducer with assistance of
staff nurse.
c) Observations recorded and report
generated by Radiologist.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
15.5 Performing CT Scan Technician/Radiologist

a) Patient arrives as scheduled with
requisition form & preadvised
preparation.
b) Can be contrast or non
contrast examination
c) For contrast examination-informed consent
as above
d) All metallic objects removed from area of
interest.
e) Patient positioned for area to be examined
f) IV contrast is injected in appropriate
quantity.
g) Scanning is to be done choosing
appropriate protocol as per indication
h) Post processing of acquired images.
i) Filming in soft tissue, lung, bone window as
appropriate in minimum of films in all
requisite information.
j) Reporting by Radiologist.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
15.6 Performing MRI Scan Technician

a), b)& c) same as CT Scan
d)contraindications to be checked
e) Patient positioned for area to be examined.
f) IV contrast if required
g) Post contrast acquisition.
h) Post processing if required.
i) Filming of required sequences
j) Reporting by Radiologist.
15.7 Performing interventions

a) Ensure availability of attendant /referring
doctor
b) Proper procedure risk assessment &
investigation as appropriate (BT/CT/INR
etc)
c) All aseptic precautions to be taken
d) Universal precaution to be followed all
the time
e) Done under USG/Fluoro/CT guidance
f) Proper labeling and identification of
sample
g) Appropriate dispatch of collected
samples to be ensured by
sister/radiologist to referring
department/concerned lab.
h) Patient to be monitored post procedure
as required.
i) Inform patient regarding report
collection
16 Radiation protection:
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
AERB guidelines and ALARA principle will be Technician/Radiologist

followed for all radiation exposures
Patient Protection: Appropriate imaging,
ascertaining pregnancy status of female patients,
use of gonadal covers/lead shields wherever
appropriate, use of low dose exposures, especially
for children.
Staff protection: Appropriate rosters/rotation of Technician & RSO
technical staff from radiation to non- radiation areas.
Provision of radiation protection barriers/ lead
apron/ thyroid shield, lead goggles/ gonadal shields
wherever
appropriate.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
Provision of TLD badges for monitoring of radiation

exposures.
Radiation workers shall mandatorily be wearing the
TLD badges during working hours.
16.4Leakage surveys of installation sites of all

radiation equipment to ensure that staff,
patient &visitors to the department are
protected. Entry to radiation rooms shall be
restricted by suitable signages and red light.
Attendants assisting the patient shall be
preferably males. Female attendants shall be
screened for pregnancy status.
17 Processing films/ images
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
After exposure and completion of procedure, films

will be processed by the available methods.
Wet processing is not used.
Dry view /laser/computer methods of image

processing are preferred. The choice will depend on
the daily throughputs.
The images will be checked for quality, patient
identity, and urgency of reporting, at the time of
compiling them for reporting in respective envelopes.
The technician in charge shall ensure that these
envelopes shall reach the reporting station in
separate piles for ‘urgent’ & ‘routine’.
Processing of CT/MRI images shall be done by the
radiologist to ensure that all findings and regions are
represented on the films with
appropriate annotations wherever necessary.
18 Report compilation: Radiologist

18.1 Radiologist will ensure compilation of an ‘in
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
context’ report taking into consideration the

clinical details provided by the referring
clinicians.
Patient identity will be checked by the
radiologist while compiling the report.
Quality of X ray/ other images will be ensured to be
of diagnostic value. Repeat scans will be ordered if
deemed necessary.
The timeline of reporting will be adhered to, as per
the defined turn around time by the department.
Turn around time for the report: The
department/hospitals shall be required to define
the turn around time of the radiology reports in
two categories for each modalities
–
a) Routine report (not more than 48 hours)
b) Urgent (not more than 6 hours)
Emergency report will also be intimated to the
treating physician verbally/telephonically.
The contents of the report shall include the following,
at the minimum--
a) Patient identification
b) Type of study, region, projection
c) Whether any I/V contrast/oral contrast
given. Please indicate the name, dose,
rate of contrast & whether any adverse
events (AE) occurred.
d) Details of any medical
preparation/sedation, if given.
e) Salient findings (positive & negative)
f) Provisional diagnosis
g) Differential diagnosis
h) Follow up advice, if any.
19 Dispatch of report/ Handover Staff/Technician
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
The department will ensure separate dispatch of

report for emergency, OPD and IPD patients.
The patient/accompanying person shall be informed
at the time of imaging, how, when &
from where the dispatch of report will be
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
Done
For IPD patients, the departmental attender will
personally collect/dispatch the report
For OPD patient, the dispatch will be done
from a common dispatch center in the
department.
For ER patients the attender from Radiology
department shall personally deliver/collect the
report.
At the time of dispatch, it shall be ensured by
checking patient identifiers that correct report
is handed over to the correct patient.
20 Maintenance of records Technician / office staff
All the departmental records shall be classified as
under:
a) Office Files
b) Leave records
c) Equipment records
d) Monitoring records
e) Material & consumable records
f) patient workload related data
g) Records pertaining to patients (e.g., request
forms, consent forms, reports and images
(hard/soft copies)
h) Others/miscellaneous
Records pertaining to patients shall be stored in

retrievable conditions for at least 2 years.
MLC records shall be in a separate cupboard under
lock & key as per rules (in department/MRD section).
All other office / maintenance records shall be
retained as per govt rules.
Department will ensure that blank forms & format
for reporting are available in the department.
21 Codes HoD
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
Display of contact number (rescue number) for all

relevant codes.
Code Blue: All staff in Radiology department
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GDMCH/RD/SOPM-01
shall be trained on CPR at least 6 monthly. Doctors

(radiologists shall be BLS/ACLS trained). Liaison with
the hospitals code blue team shall be done for
smooth rescue.
Code blue teams shall be made. Mock drills shall be
carried out at least 6 monthly to ensure compliance.
Code Red & code violet: all staff shall be trained.
22 Inventory Control Technician/Store keeper

Departmental inventory of material shall be
maintained by the store In charge or technician
incharge.
The following shall be defined for each items
a) Buffer stock
b) Re order level
Issue register shall be maintained & kept up to date
All instance of stock outs/ non moving
stock/expired unused stock shall be logged &
analysed in departmental committee for
appropriate CAPA.
23 Equipment maintenance– repair & /Technician/Radiologist

downtime management
Downtime of equipment clause shall be
incorporated in every equipment
maintenance contract
Contingency plan for downtime of each equipment
shall be documented. It will ensure uninterrupted
patient service.
Periodic preventive maintenance calendar for all
equipment shall be available along with contact
details of each vendor.
Response time for complaints shall be
monitored for each equipment.
Timely renewal of maintenance contract &
statuary compliance shall be ensured.
RADIO DIAGNOSIS,

GDMCH/RD/SOPM-01
24 Day to day working of the department HOD Radiology
HoD shall ensure the following (at minimum) for

smooth day to day functioning of the department
RADIO DIAGNOSIS,

a) Rosters
b) Leave Records
c) Grievance handling
d) Disciplinary procedure
e) Facility Management
f) Housekeeping
g) The HoD will take daily/weekly, scheduled
and unscheduled rounds to ensure good
facility management & housekeeping
* ABC analysis divides an inventory into three categories- "A items" with very tight control and accurate records,
"B items" with less tightly controlled and good records, and "C items" with the simplest controls possible and
minimal records.

Sop Radiology Dec Final

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GDMCH/RD/SOPM-01

Government Dharmapuri Medical College

Standard Operating Procedures Manual

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

Issue No: 01 Issue Date: 01.06.2022

S.No Contents Page

9 Scope of services – microbiology

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

Guideline for using Amendment Record sheet:

This Standard Operating Procedure Manual belongs to Radio diagnosis Department of

S.No. Issu Procedure Date of Amendment Reasons Amended Approved

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

Dr A.ARUMUGAM MBBS DMRD.,

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

Tamil Nadu – 636 701

Name&Designation : Dr A.ARUMUGAM MBBS DMRD

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

CONTROL OF THE MANUAL

AUTHORITY OVER CONTROL OF

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

DISTRIBUTION LIST OF MANUAL

S.NO DESIGNATION SIGNATURE

3. NABH Nodal Officer

4. NABH Quality Manager

5. Professor & Head of Dept of Radio diagnosis

6. Senior Resident Dept of Radio diagnosis

7. Radiation Safety Officer RSO

8. Chief X Ray Technician for Radio diagnosis

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

DISTRIBUTION LIST OF MANUAL

12 Suresh Kumar Radiographer(CT-SCAN)

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

S. No. Title Pages

1 Radio diagnosis Policy 8-23

1 Radio diagnosis SOPs 24-54

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

RADIO DIAGNOSIS DEPARTMENT POLICY

b. Department chooses leaders and establishes hierarchy in the department.

Name Of The Post Name Of The Staff

c. Department ensures acquisition of all relevant licenses and their updation.

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL DHARMAPURI

1 ORAL PANTOMOGRAM 2 CONVENTIONAL ANGIOGRAM

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

6 CRANIUM மூளை 6 SCROTUM DOPPLER டாப்ளர்

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL DHARMAPURI

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL DHARMAPURI

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

2. PATIENT REGISTRATION POLICY

c. each patient is identified by his/her name, age sex and IP / OP number.

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

the clinical indication.

3 PATIENT INFORMATION POLICY

e. Confidentiality of patient information will be maintained.

f. Patient and family have a right to seek an additional opinion.

4 INFORMED CONSENT POLICIES

a. the list of situations where informed consent is required is available

5 EMERGENCY STUDT POLICIES

GOVERNMENT DHARMAPURI MEDICAL COLLEGE HOSPITAL

b. Emergency studies are prioritized during imaging and reporting.

c. medico-legal cases are documented and labeled properly.

d. all staff are oriented towards emergency cases

PATIENT TRANSPORT POLICY