STANDARD OPERATING PROCEDURE FOR

X-RAY EXAMINATIONS

ALBURY WODONGA HEALTH

WODONGA CAMPUS
 STANDARD OPERATING PROCEDURE FOR X-RAY EXAMINATIONS

TABLE OF CONTENTS

GLOSSARY OF TERMS IN THIS STANDARD OPERATING PROCEDURE: ...................................... 3

INTRODUCTION:.................................................................................................................................... 5

PROCEDURE FOR IDENTIFICATION OF INDIVIDUALS UNDERGOING A MEDICAL EXPOSURE: 6

PROCEDURE FOR MAKING ENQUIRES OF FEMALES OF CHILDBEARING AGE:.......................... 8

PROCEDURE FOR CLINICAL HANDOVER: ....................................................................................... 10

PROCEDURE FOR JUSTIFICATION / AUTHORISATION OF A MEDICAL EXPOSURE: ................. 12

PROCEDURE FOR REVIEW OF JUSTIFICATION PROTOCOLS:..................................................... 15

PROCEDURE FOR THE DOCUMENTATION OF THE PATIENT DOSE: .......................................... 16

PROCEDURE FOR MONITORING DOSE: .......................................................................................... 17

PROCEDURE FOR MONITORING REJECT ANALYSIS OF X-RAY IMAGES: .................................. 18

PROCEDURE FOR ACCIDENTAL OR UNINTENDED RADIATION EXPOSURE: ............................. 19

PROCEDURE FOR ENSURING THAT ALL OPERATORS UNDERSTAND THE PRINCIPLES OF

DOSE REDUCTION:............................................................................................................................. 20
PROCEDURE FOR THE PROVISION OF X-RAY IMAGING PROTOCOLS AND STANDARD

EXPOSURE FACTORS: ....................................................................................................................... 21

SYSTEMS OF WORK FOR RADIOGRAPHERS: ................................................................................ 22

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GLOSSARY OF TERMS IN THIS STANDARD OPERATING PROCEDURE:

Australian Health Practitioner Regulation Agency (AHPRA):

The Health Professional council area regularity body who’s function is maintaining and publishing a
public register of properly qualified members of the professions. They approve and uphold high
standards of education and training and investigating complaints and taking appropriate action.

ALARA:
As Low As Reasonably Achievable:
Radiation must be kept As Low As Reasonably Achievable (ALARA). The principle that radiation
exposures must be reduced to the lowest level that can reasonably be achieved.

CPD:
Continuous Professional Development.

DI:
Dose Index:

EXI:
Exposure Index:
Reference tool that can be used to ensure that the exposure settings being applied are within an
appropriate range.

LMP:
Last Menstrual Period.
By convention, pregnancies are dated in weeks starting from the first day of a woman's last menstrual
period (LMP). If her menstrual periods are regular and ovulation occurs on day 14 of her cycle,
conception takes place about 2 weeks after her LMP.

Operator:
Radiology technicians, technologists, and sonographers fall within the broad scope of a radiography
profession. Using radiation in the form of x-rays, magnetic resonance imaging and ultrasound,
radiographers assess, diagnose and treat patients for a variety of injuries and diseases, Often part of
a medical or surgical team, radiographers are typically involved in initial patient evaluation and testing,
providing diagnostic and evidentiary data for Physicians.

PACS:
Picture Archiving and Communications System:
A network of computers used by radiology departments that replaces film with electronically stored
and displayed digital images. It provides archives for storage of multimodality images, integrates
images with patient database information, facilitates laser printing of images, and displays both
images and patient information at work stations throughout the network. It also allows viewing of
images in remote locations.

RIS:
Radiology Information System.
A RIS is a computerised database used by radiology departments to store, manipulate, and distribute
patient radiological data and imagery. The system generally consists of patient tracking and
scheduling,

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result reporting and image tracking capabilities. RIS complements Hospital Information Systems
(HIS), and is critical to efficient workflow to radiology practices.

Radiation (Ionising):
Radiation that produces ionisation in matter. Examples are alpha, beta, gamma and x-radiation and
neutrons. When these radiations pass through the tissues of the body, they have sufficient energy to
damage DNA.

Radiation Medical Practitioner:

A radiologist is a physician who reads and interprets digital images, or x-rays, of patients obtained
through a variety of cameras, machines, and imaging equipment. The radiologist uses this information
to help diagnose the patient and consult with the treating Physician to develop a course of treatment.

Referral or Request Form:

A request for a diagnostic imaging examination or procedure usually requires the completion of a
written request or referral form, via which key information is communicated to the imaging facility from
the referring Practitioner.

Radiation Medical Practitioner:

A radiologist is a physician who reads and interprets digital images, or x-rays, of patients obtained
through a variety of cameras, machines, and imaging equipment. The radiologist uses this information
to help diagnose the patient and consult with the treating Physician to develop a course of treatment.

RSO:
Radiation Safety Officer
The appointed person to advise AWH Management and Executive on all matters relating to radiation
safety with the Organisation. In this case the RSO is the Practice Manager.

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INTRODUCTION:
Standard Operating Procedures (SOPs) are succinct formal documents designed to achieve
consistency by specifying standard practice in performing those functions.

AIM:
This document covers all practical issues required to comply with Code of Practice for Radiation
Protection in Medical Applications of Ionizing Radiation 2008.

PURPOSE AND SCOPE:

The purpose of this SOP is to describe the process of radiation for any patient undergoing an x-ray
examination.
The SOP will cover:
· Procedure for identification of individuals undergoing an x-ray examination.
· Procedure for making enquires of females of childbearing age.
· Procedure for clinical handover in Medical Imaging.
· Procedure for justification / authorisation of an x-ray examination.
· Procedure for Review of Justification Protocols.
· Procedure for the assessing of the patient radiation dose.
· Procedure for setting and monitoring diagnostic reference levels.
· Procedure for accidental or unintended radiation exposure.
· Procedure for Ensuring that all Operators understand the Principles of Dose Reduction.
· Procedure for the Provision of X-ray Imaging Protocol and Standard Exposure Factors.
· Systems of Work for Operators.

This SOP will be followed by all staff involved in the use of x-ray equipment. All members of staff who
use radiation, or are in any way involved with its use, shall do so only in accordance with State
Registrations. Staff who work with radiation shall exercise reasonable care, use any protective
equipment provided, report any defect in such equipment, wear any radiation monitors provided and
undertake any training deemed necessary.

ROLES AND RESPONSIBILITIES:

Key roles and responsibilities are defined in the Code:
· The Responsible Person (Management Licence Holder): the person who has the overall
management responsibility of the radiation source or practice.
· The Medical Radiation Practitioner: the person responsible for the justification and
optimisation of the medical procedure involving the exposure of the patient to ionizing
radiation.
· The Operator: the person who exposes the patient to ionizing radiation.

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PROCEDURE FOR IDENTIFICATION OF INDIVIDUALS UNDERGOING A MEDICAL EXPOSURE:

PURPOSE:
To ensure the correct identification of patients prior to exposure.

SCOPE:
All X-ray examinations.

RESPONSIBILITIES:
The operator initiating the exposure is responsible for ensuring the final check of patient identity has
been made before proceeding. The operator checking patient identity will adhere to this procedure.

PROCEDURE:
· The operator must undertake a positive patient identification (PPI) check and therefore they must
ask the patient to state their name, address and date of birth. These details must be checked
against the request form and if there are any discrepancies these must be investigated before
undertaking the examination. (Refer to Annex 1)
· If the operator is satisfied that they have the correct patient they will sign the ‘Time Out’ stamp on
the referral. This will be scanned into the patient’s records on Radiology Information System
(RIS) for reference.
· For patients unable to communicate through illness, physical or mental disability or language
barrier, check identification bracelets or ask an escorting relative, carer or interpreter. A positive
identification must be given.
· If there is no escort or identification bracelet on a patient, who is unable to give their details,
contact the referring department and ask for someone who can identify that patient, such as a
nurse or relative, to visit and identify the patient. The person who checks the patient identity will
sign the request form in the “time out” stamp.
· A history of any previous relevant X-ray investigations should, whenever possible, be taken from
the patient prior to carrying out the new procedure to correlate the clinical detail provided on the
radiology request form to that patient The RIS and Picture Archive and Communication System
PACS should be checked in every patient contact to ensure up to date records and any previous
radiology or information.

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FLOW CHART FOR THE PROCEDURE OF POSITIVE PATIENT IDENTIFICATION (PPI)

UNDERGOING AN X-RAY EXAMINATION

Medical Imaging with referral and details entered/confirmed

onto RIS

Patient enters Xray Room

Positive Patient Identification (PPI)
performed

PPI criteria satisfied PPI criteria NOT

satisfied

PPI ‘Time Out’ documentation Additional information required

performed from alternate source

PPI criteria NOT satisfied

Examination undertaken
subject to justification Examination not
performed

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PROCEDURE FOR MAKING ENQUIRES OF FEMALES OF CHILDBEARING AGE:

PURPOSE:
To prevent unnecessary irradiation of a foetus from a medical exposure by ensuring enquiries with
regard to pregnancy are made in an appropriate and consistent manner.

SCOPE:
All women of childbearing age who are to undergo X-ray examinations.

RESPONSIBILITY:
The operator initiating the exposure is responsible for ensuring the final check of pregnancy has
been made before proceeding. The operator checking pregnancy will adhere to this procedure.
(Refer to Annex 2)

PROCEDURE:
The operator will require the outpatients to complete and sign the Pregnancy Questionnaire that will
include questions on pregnancy and LMP (Refer to Outpatient Pregnancy Questionnaire (Females
Aged 12 - 55 Years) Radiation Form). For inpatients, the requesting doctor will complete a
pregnancy information section as part of the Request Form If the patient states that she is NOT
pregnant following choosing one of the reasons in the table below then proceed with the exposure.
The patient should sign the Pregnancy Questionnaire and this needs to be scanned into the patient’s
file on the RIS.

Do you meet one of the following criteria? It is not necessary to say which one:
· Not sexually active
· Tubal Ligation
· Hysterectomy
· Post-Menopausal
· Partner has had a vasectomy
· Negative Pregnancy Test (BHCG)
· Currently Menstruating
· Mirena / Implanon

· If the patient states that she IS pregnant and the area to be examined includes the pelvis:
Consult with the Radiologist to check if the procedure may be safely deferred. The Radiologist
may contact the referrer directly or delegate the task to the operator.

If the procedure cannot be deferred justification can only be approved by the Medical Radiation
Practitioner. If the outcome of the decision is that the procedure is justified and must proceed due
to its nature, then Radiation in Pregnancy consent form (Refer to Radiation in Pregnancy Consent
Form) should be administered by the Medical Radiation Practitioner. Risks vs benefits should
be concisely explained to the pregnant patient.

· For patients unable to communicate through illness, physical or mental disability or language
barrier, all questions relating to pregnancy will be addressed to an escorting relative, carer or
interpreter.

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FLOW CHART FOR PROCEDURE OF ASSESSING WOMEN OF CHILDBEARING AGE

Female Patient of Child Bearing Age (12 - 55 yrs)

Pregnancy status
questionnaire.
Is the patient pregnant?

No Unsure Yes
(Criteria satisfied)

Proceed Consult with Medical

(Status documented) Radiation Practitioner

Area of
examination

Area other than Pelvis

pelvis

Proceed with Non Urgent Consult with Medical

lead shielding Radiation
Practitioner

Urgent
> 10 days from LMP Follow 10 Day Rule

Rebook when status < 10 Days from LMP Pregnancy test to

verified be organised
Do you meet one of the following criteria?
It is not necessary to say which one:
· Not sexually active
· Tubal Ligation
· Hysterectomy
· Post-Menopausal
· Partner has had a vasectomy
Proceed if
· Negative Pregnancy Test (BHCG) examination justified
· Currently Menstruating
· Mirena / Implanon

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PROCEDURE FOR CLINICAL HANDOVER:

PURPOSE:
The aim of this procedure is to ensure continuity of patient care and safety.

SCOPE:
Inter-departmental patient transportation.

RESPONSIBILITY:
All staff

PROCEDURE:
· Ensure that clinical handover is performed in accordance with AWH Clinical Handover Policy.
(Refer AWH Clinical Handover Policy)
http://wrhsshpt/PP_Pdf/Policies_and_Procedures/Policies/Clinical%20Handover%20Policy.pdf
· Ensure adherence to the ISBAR chart. (Refer Annex 3)
· Any incidents relating to clinical handover are reported in the Incident Management System.

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Medical Imaging Nurse / Medical Imaging

Attending Nurse
Technologist Nurse / Technologist
I Introduction Identify yourself and role Identify yourself to the
to the patient and nurse
attending nurse

S Situation and Communicate to the Communicate patient Communicate to nurse

Status patient and nurse what information what examination has
examination has been o Presenting problem been performed
requested. If applicable o Current status
ensure preparation o Medications reviewed
requirements have been o Mobility
fulfilled. o Cognitive status,
o NFR status
o Alerts
B Background What is the clinical
background or context
o Relevant past history
o Co-morbidities
o Recent issues -
health and social

A Assessment o Assessment findings o Peri-examination

o Current clinical status information, eg:
o Current vital signs Cannula re-sited,
contrast
extravasation,
unsatisfactory
bowel preparation
R Recommendations Communicate patient Communicate post
Repeat information requirements examination patient
to confirm o Immediate needs - requirements
understanding meds, monitoring, o Ask the patient if
O2, PAC, etc they have any
o Ask the patient if they questions
have any questions

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PROCEDURE FOR JUSTIFICATION / AUTHORISATION OF A MEDICAL EXPOSURE:

PURPOSE:
The Department of Health Victoria requires every medical exposure to be justified and authorised in
advance, in accordance with clause 3.3.3 of the Code. This procedure states how that justification
takes place and how the operators conducting a medical exposure are made aware of the fact that
justification has occurred. Justification of X-ray examinations is a wide and varied entity. To provide
justification criteria for all examinations is unrealistic.

SCOPE:
All X-ray examinations.

RESPONSIBILITY:
It is the responsibility of the Medical Radiation Practitioner to authorise each exposure (generically)
only if it is justified. It is the responsibility of the operator to effect a medical exposure only once
authorisation has been obtained.

PROCEDURE:
· Medical Radiation Practitioners are entitled provide generic justification for X-ray examinations.
When justifying a medical exposure, consideration should be given to the following points:
- The objectives of the exposure.
- The direct health benefit to the individual.
- The individual detriment the exposure may cause.
- The benefits and risks of alternative techniques which may meet the objectives with less or
no detriment.

· The following matters will demand special attention:

- Exposures on medico-legal grounds.
- Exposures with no direct health benefit to the individual being exposed.
- Exposure of females who are, or may be pregnant.
- Urgent / out of hour’s exposures.
- Children.

- The Operator may consider the examination to be generically justified provided that:
- There is generic justification according to the protocol (Refer to document Generic
Justification of x-ray examinations) AND
- There is clinical question
- The clinical question can be answered by the examination

If sufficient clinical information is not made available by the referrer the Radiology Request Form will
be returned in the cases of non-urgent referrals. In the case of urgent referrals the Medical Radiation
Practitioner will arrange for the referrer to be contacted to obtain the relevant information. The
Practitioner will arrange for the non-urgent Radiology Request Forms to be returned with a tick chart
(Refer to Incomplete Imaging Request Return Form) identifying additional information required
attached.

· The examination must not proceed until the operator has either (Refer to Annex 4):
- Determined that the examination is generically justified OR

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- Had the examination justified individually and set a specific protocol by the Medical
Radiation Practitioner.
- In both cases there must be documented evidence ie signature of the individual who
has deemed the examination justified. This is then to be scanned into the patient’s file
on the RIS

· The Operator is entitled to refer the process to justification on an individual basis by the
Radiation Medical Practitioner at any time.

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JUSTIFICATION AND APPROVAL FLOW CHART

Medical Practitioner

PREGNANT PATIENTS
REQUIRE JUSTIFICATION
THE RADIATION MEDICAL
PRACTITIONER WHERE
Referral received from THE PRIMARY BEAM WILL
Medical Practitioner IRRADIATE THE FOETUS
DIRECTLY

Generic Justification Justification by Radiation

A clinical question is asked that can Medical Practitioner
Reasonably be answered by the examination Assessment performed by the Radiation Medical
Practitioner in accordance with requirements of
section 3.2 of the Code

Insufficient Justified Uncertain Justified Insufficient Cannot be justified

clinical notes Clinical Notes

Approval Not Approved Approval

Performed by Operator in accordance with Operator requests Performed by the Radiation Medical
guidelines established by the |Medical justification on individual Practitioner in accordance with Section 3.2
Radiation Practitioner basis of the Code

Examination Proceeds
Justification documented in patient’s file on RIS

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PROCEDURE FOR REVIEW OF JUSTIFICATION PROTOCOLS:

PURPOSE:
The Department of Health Victoria requires every medical exposure to be justified and authorised in
advance, in accordance with clause 3.3.3 of the Code. This procedure states the process for review of
generic justification protocols.

SCOPE:
All generic justification protocols for X-ray examinations

RESPONSIBILITY:
It is the responsibility of the Medical Radiation Practitioner in conjunction with the Chief Radiographer to
ensure that all generic justification protocols are reviewed regularly.

PROCEDURE:
· The generic justification protocols should be reviewed by the Radiation Medical Practitioner every 12
months.
· The generic justification protocols should be reviewed on the installation of new software or
equipment.
· The generic justification protocols should be reviewed by request of the Radiation Medical Practitioner
at all other times.

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PROCEDURE FOR THE DOCUMENTATION OF THE PATIENT DOSE:

PURPOSE:
To detail how patient dose indicators are recorded for each medical exposure.

SCOPE:
Covers all X-ray examinations.

RESPONSIBILITY:
It is the responsibility of the operator who initiates the exposure to ensure that the appropriate patient dose
indicator is recorded.

PROCEDURE:
· The X-ray equipment will automatically document dose related information on the patient’s images
which are stored and available of PACS.

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PROCEDURE FOR MONITORING DOSE:

PURPOSE:
To perform review of EXI and DI trends and to take corrective action if discrepancies are discovered.

SCOPE:
Observation of X-ray examination DI and EXI statistics. Discrepancies may indicate equipment fault or the
need to adjust protocols.

RESPONSIBILITY:
The X-ray Team Leader will investigate excessive doses and implement corrective action. The X-ray Team
Leader may delegate this role as appropriate.

PROCEDURE:
· At least every six months the X-ray team Leader will perform a patient dose audit and provide a
report.
· The X-RAY Team Leader will review the results to establish where discrepancies exist.
· The X-RAY Team Leader will investigate excessive doses and implement corrective action.

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PROCEDURE FOR MONITORING REJECT ANALYSIS OF X-RAY IMAGES:

PURPOSE:
To identify the procedure for the provision of reject analysis for the purpose of quality assurance.

SCOPE:
The X-ray Team Leader is responsible for analysis of all reject x-ray images.

PROCEDURE:
· The reason for image rejection is to be recorded and classified.
· Data is recorded and reject analysis is to be performed every 3 months.
· A report of the reject analysis is to be reported to the RSO.
· Any trends are to be investigated and addressed.

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PROCEDURE FOR ACCIDENTAL OR UNINTENDED RADIATION EXPOSURE:

PURPOSE:
To ensure that all accidental and unintended exposures to patients or participants are properly investigated
and recorded.
To ensure that reportable incidents are reported to the appropriate authority.

SCOPE:
Covers all X-ray examinations.

PROCEDURE:
Any member of staff who suspects that an accidental, unnecessary or unintended exposure has occurred
will, as soon as possible, record relevant information and report full details of the incident to the RSO and
record the incident on VHIMS. The RSO will arrange for an investigation to be carried out immediately as
per the Radiation Management Plan. (Refer to Radiation Management Plan)
· Patients who undergo a procedure that was not intended, as a result of mistaken identification or other
procedural failure, and consequently have been exposed to an ionising radiation dose, must be
considered as having received an unintended dose of radiation.
· If the person reporting the incident has reason to believe it was caused by a radiation equipment fault,
that person will advise other staff not to use the suspect equipment until it has been checked. The
RSO will arrange for an assessment of the equipment to be made and will not allow it to be used for
medical exposures until it is demonstrated that its performance is reliable and within recommended
QA standards.

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PROCEDURE FOR ENSURING THAT ALL OPERATORS UNDERSTAND THE PRINCIPLES OF DOSE
REDUCTION:

PURPOSE:
This is to ensure Radiation Dose should be managed and minimized following As Low As Reasonably
Achievable (ALARA) principle.

SCOPE:
All staff using the X-ray Equipment should follow to procedure to reduced radiation exposure.

PROCEDURE:
· Departmental staff meetings, during which radiation protection information is disseminated, are held
regularly and minuted. These meetings include Practice Manager Meetings, Directorate Meetings and
general staff meetings.
· The identity of the patient is checked prior to any radiation exposure.
· All equipment is subject to regular preventative maintenance and independent radiation safety and
performance assessment.
· X-ray equipment faults are logged and reported to the Chief Radiographer / RSO.
· All staff receive appropriate in-house training on the operation of equipment.
· All untoward incidents are reported to the RSO and logged on VHIMS.
· All radiation incidents are reported and investigated.
· The cause of radiation incidents are reviewed and appropriate action taken to minimise the risk of
recurrence.
· Care is taken at all times whilst examining patients to select the most appropriate examination settings
and operate it in accordance with manufacturer’s instructions and operate in accordance with
manufacturer’s guidelines.

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PROCEDURE FOR THE PROVISION OF X-RAY IMAGING PROTOCOLS AND STANDARD

EXPOSURE FACTORS:

PURPOSE:
To identify the procedure for the provision of imaging protocols (standard image sequences) and the
setting of standard exposure factors.

SCOPE:
All X-ray examinations.

PROCEDURE:
· Standard imaging protocols are agreed by the Medical Radiation Practitioner and the Chief
Radiographer. No alterations can be made to these protocols without consent of the Medical
Radiation Practitioner.
Standard exposure factors for each type of X-ray examination are stored within the X-ray equipment’s
anatomical programme lists and documented with Justification Positioning and Exposure Protocols for
X-Ray Examinations Procedure.
· Any adjustment to the programmed exposure factors must be authorised by the X-ray Team Leader.

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SYSTEMS OF WORK FOR RADIOGRAPHERS:

· Only AHPRA registered staff trained to operate the X-ray Equipment are permitted to do so.

· Do not enter the X-ray room if the x-ray warning light is illuminated.

· All doors must be closed during the X-ray examination.

· All exposure parameters are to be checked prior to performing the X-ray examination.

· PPE must be worn by any individual (other than the patient) who is present in the Xray room,
unless protected by the lead lined screen.

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Annexes:

Related AWH Documents:

Accreditation Standards:

Other Relevant Information:

References:

Contact Point: Medical Imaging.

In consultation with:
TITLE / POSITION

THIS SECTION FOR QUALITY & CLINICAL GOVERNANCE OFFICE USE ONLY
Approved by Executive / Delegate: Date Approved: SharePoint Location:
Executive Director of Medical Services 3 November 2015 Other…
and Clinical Governance
Responsible Department: Date for Review: Linked Documents:
Medical Imaging 3 November 2018
Version No: Original Approval Date: Previously Named As:
1 3 November 2015

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