Articles and Case Studies
Radiology FAQs
How do I manage the situation when a doctor has ordered a test which I don’t think is appropriate?
The Royal Australian and New Zealand College of Radiology (RANZCR) Standards1 include:
The practice has documented procedures for reviewing requests which ensure that the requested examination is appropriate to the needs of the referrer and the patient…
When it is determined… that a different diagnostic imaging examination or modality would be more appropriate, or an additional examination is necessary, the appropriate test(s) shall be performed and all reasonable steps shall be taken to contact the requesting practitioner before providing the substituted or additional examination or modality.
The substitution should be noted in the report. Communication and attempts to contact the referrer should be documented, and the patient should be informed and consented.
The manner in which you communicate with the referrer in this circumstance is vital for maintaining a good relationship with them. Being friendly and non-judgemental is a good approach.
What should I do if a patient has been referred but does not attend?
The clinical significance of the situation should guide your response. If the patient has been triaged as urgent, it would be best to:
If the patient has been triaged as urgent and cannot be contacted:
What is my obligation to contact the referrer with abnormal test results?
There have been claims against Radiologists involving failure to contact a referrer about abnormal test results.2 The RANZCR Standards3 include:
If there are urgent and significant unexpected findings, there is a protocol which ensures that:
a) the reporting radiologist uses
b) all reasonable endeavours to communicate directly with the referrer or an appropriate representative who
c) will be providing clinical follow-up;
d) a record of actual or attempted direct communication is maintained by the practice; and
e) the reporting radiologist co-ordinates appropriate care for the patient if they are unable to communicate such findings to the referring clinician
Is it enough to fax the results?
This depends on the clinical significance of the results, the likelihood that the referrer’s practice will be open so the fax can be attended to, and your agreement with the referrer on the best way to send results.
Do I need to record after-hours numbers of referring doctors?
It is best to have an after-hours number for referrers, and to have an agreement with the referrers about what circumstances will prompt you to call them after hours.
Who is responsible for ensuring the referring doctor receives a report following an image-guided biopsy?
As the person who writes the report, the Pathologist is responsible for providing the report to the referring doctor. However, as the one doing the biopsy, the Radiologist is an integral part of the process and would be expected to have systems in place to ensure all referrals are acted on in a timely manner; all biopsies are received by the Pathologist in a timely manner; and an audit trail can be followed in the event that the report is not received by the referring doctor.
If a female patient has had a CT scan of her lumbar spine and subsequently discovers she is pregnant, what should I tell the referring doctor?
It will be important that the referring doctor speaks to the patient about the theoretical risks. You can advise the referring doctor of the current scientific thought on the implications for the patient and the foetus.
A good source to refer them to may be Radiation Risk of Medical Imaging during Pregnancy on the Inside Radiology website.
You should also advise the referrer of your consent process for the CT scan, in particular regarding pregnancy.
If the incorrect side has been imaged, should I inform the patient or the referring doctor?
The Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia states:
When adverse events occur, you have a responsibility to be open and honest in your communication with your patient, to review what has occurred and to report appropriately.
In line with the principles of open disclosure4 and for ongoing care of the patient, as the Radiologist you should inform the patient and the referring doctor. A full explanation should be provided to the patient, including an apology or expression of regret, how it occurred (if known), what the implications are for the patient, and what will be done to prevent it happening again. Your explanation should be in layman’s terms that the patient can understand. You should be empathetic to the patient and allow them to talk and ask questions.
What do I do if a patient reports me to APHRA and has threatened legal action?
Call MDA National immediately so we can look after your best interests. Legal action, complaints and disciplinary processes can be personally and professionally distressing. We are here to support you with knowledge about the process and on what to expect, and guide you to other sources of support such as:
and medico-legal issues, check out our medico-legal pull-out in Defence Update Summer 2014/15.
What should I do if a patient requests a copy of their Radiology results?
Privacy law entitles patients to access their medical records. Your practice is required
to provide personal information held about an individual on request (unless a specific exception applies).5 You must:
You may impose a charge for giving access, provided the charge is not excessive (e.g. for photocopying, postage, staff time).
If you have concerns about providing a copy of results in a particular circumstance, phone MDA National for advice.
If an employer or insurer is paying for an examination, there should be a written agreement between the payer and the patient as to who owns the results; and the Radiology practice should be clear about what authorisations are necessary to provide a copy of the results.
What should I document about the consent process?
The Royal Australian and New Zealand College of Radiology’s (RANZCR) Medical Imaging Consent Guidelines provide a good guide to documenting consent:
When obtaining consent at the time of the examination, the form of consent and the manner in which consent is recorded will differ depending on the type of examination, the degree of risk and, in emergencies, whether the imaging is time-critical. The more complex the medical imaging examination or the greater the risks, the more important it is to have formal documentation of the consent process. However, the way in which consent is recorded is left to the individual Radiologist’s judgement.
Implied consent occurs usually with very low-risk procedures such as when consent is implied by a patient placing their hand in an x-ray machine.
Verbal consent involves a discussion about what a procedure will involve and its risks and benefits, allowing a patient to decide if they are happy to proceed. A contemporaneous note of this discussion should be made and kept in the patient’s records.
Written consent provides evidence of what the consent process involved and should be kept in the patient’s records RANZCR’s Medical Imaging Consent Guidelines give the following examples of when written consent should be obtained:
What should we be doing to maintain patients’ privacy in the waiting room?
To protect patients’ confidentiality, their details should not be overheard or seen by other people in the waiting room. Options include:
What steps are required in the management of a patient who:
1. Says they have had an allergic reaction to IV contrast in the past
Previous reaction to contrast media is the most important risk factor of a contrast procedure, and carries a 20-60% absolute risk during subsequent exposure.6 The risk of a contrast reaction should be carefully weighed against the benefit expected from doing the examination. Any other known risk factors should also be taken into consideration. The patient must be warned of the risks and provided with enough information that they can make an informed decision about whether to have the examination. In many instances where the patient has previously had an allergic reaction it will be wise to involve the referring doctor as well.
The RANZCR Guidelines for Iodinated Contrast Administration7 (the guidelines) advise:
If it is decided to proceed with the contrast-enhanced study, specific recommendations about the agent and its administration are made in the guidelines.
2. Has an allergic reaction to IV contrast
The guidelines detail specific interventions according to the reaction, ranging from supportive measures for mild urticaria to oxygen, IV fluids and adrenaline for moderate isolated hypotension.
3. Has a severe anaphylactic reaction?
The guidelines contain specific instructions, including the dosage of adrenaline, which is life-saving and must be used promptly.
A Radiology practice which administers contrast should have, in line with the RANZCR standards:
How much detail is needed in the medical records?
The Medical Board of Australia’s code of conduct8 states:
Good medical practice involves:
8.4.1 Keeping accurate, up-to-date and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management
…
8.4.4 Ensuring that the records are sufficient to facilitate continuity of patient care.
The Radiologist’s interpretation of imaging findings has a direct impact on the safety and appropriateness of a patient’s ongoing care. Appropriate documentation in the Radiology report is detailed in RANZCR’s Radiology Written Report Guidelines9 with the content structured by:
The Radiology Written Report Guidelines also address the format of the report and style of expression.
Proof-reading the report for accuracy before delivery is also crucial. t.
Besides the report, your records should include:
References
The practice has documented procedures for reviewing requests which ensure that the requested examination is appropriate to the needs of the referrer and the patient…
When it is determined… that a different diagnostic imaging examination or modality would be more appropriate, or an additional examination is necessary, the appropriate test(s) shall be performed and all reasonable steps shall be taken to contact the requesting practitioner before providing the substituted or additional examination or modality.
The substitution should be noted in the report. Communication and attempts to contact the referrer should be documented, and the patient should be informed and consented.
The manner in which you communicate with the referrer in this circumstance is vital for maintaining a good relationship with them. Being friendly and non-judgemental is a good approach.
What should I do if a patient has been referred but does not attend?
The clinical significance of the situation should guide your response. If the patient has been triaged as urgent, it would be best to:
- phone the patient and reschedule as soon as possible send an appointment confirmation to the patient (by means agreed to by the patient, e.g. SMS/letter)
- notify the referrer of the changed appointment (by phone) if the referrer made the appointment for the patient.
If the patient has been triaged as urgent and cannot be contacted:
- notify the referrer (by phone and in writing – as agreed by referrer: email, fax, letter)
- leave a message asking the patient to contact you
- document all attempts to contact the patient.
What is my obligation to contact the referrer with abnormal test results?
There have been claims against Radiologists involving failure to contact a referrer about abnormal test results.2 The RANZCR Standards3 include:
If there are urgent and significant unexpected findings, there is a protocol which ensures that:
a) the reporting radiologist uses
b) all reasonable endeavours to communicate directly with the referrer or an appropriate representative who
c) will be providing clinical follow-up;
d) a record of actual or attempted direct communication is maintained by the practice; and
e) the reporting radiologist co-ordinates appropriate care for the patient if they are unable to communicate such findings to the referring clinician
Is it enough to fax the results?
This depends on the clinical significance of the results, the likelihood that the referrer’s practice will be open so the fax can be attended to, and your agreement with the referrer on the best way to send results.
Do I need to record after-hours numbers of referring doctors?
It is best to have an after-hours number for referrers, and to have an agreement with the referrers about what circumstances will prompt you to call them after hours.
Who is responsible for ensuring the referring doctor receives a report following an image-guided biopsy?
As the person who writes the report, the Pathologist is responsible for providing the report to the referring doctor. However, as the one doing the biopsy, the Radiologist is an integral part of the process and would be expected to have systems in place to ensure all referrals are acted on in a timely manner; all biopsies are received by the Pathologist in a timely manner; and an audit trail can be followed in the event that the report is not received by the referring doctor.
If a female patient has had a CT scan of her lumbar spine and subsequently discovers she is pregnant, what should I tell the referring doctor?
It will be important that the referring doctor speaks to the patient about the theoretical risks. You can advise the referring doctor of the current scientific thought on the implications for the patient and the foetus.
A good source to refer them to may be Radiation Risk of Medical Imaging during Pregnancy on the Inside Radiology website.
You should also advise the referrer of your consent process for the CT scan, in particular regarding pregnancy.
If the incorrect side has been imaged, should I inform the patient or the referring doctor?
The Medical Board of Australia’s Good Medical Practice: A Code of Conduct for Doctors in Australia states:
When adverse events occur, you have a responsibility to be open and honest in your communication with your patient, to review what has occurred and to report appropriately.
In line with the principles of open disclosure4 and for ongoing care of the patient, as the Radiologist you should inform the patient and the referring doctor. A full explanation should be provided to the patient, including an apology or expression of regret, how it occurred (if known), what the implications are for the patient, and what will be done to prevent it happening again. Your explanation should be in layman’s terms that the patient can understand. You should be empathetic to the patient and allow them to talk and ask questions.
What do I do if a patient reports me to APHRA and has threatened legal action?
Call MDA National immediately so we can look after your best interests. Legal action, complaints and disciplinary processes can be personally and professionally distressing. We are here to support you with knowledge about the process and on what to expect, and guide you to other sources of support such as:
- your colleagues, your family, and your GP
- independent bodies such as the Doctors’ Health Advisory Service or the Medical Benevolent Association
- medical support offered by the MDA National programs:
- Doctors for Doctors or
- Professional Support Service.
and medico-legal issues, check out our medico-legal pull-out in Defence Update Summer 2014/15.
What should I do if a patient requests a copy of their Radiology results?
Privacy law entitles patients to access their medical records. Your practice is required
to provide personal information held about an individual on request (unless a specific exception applies).5 You must:
- verify that the request was made by the individual concerned
- respond to a request for access within 30 calendar days
- give access to the information in the manner requested by the individual, if it is reasonable and practicable to do so
- (for example in hard or soft copy)
- give the individual a written notice if you refuse to give access, or refuse to give it in the manner requested.
You may impose a charge for giving access, provided the charge is not excessive (e.g. for photocopying, postage, staff time).
If you have concerns about providing a copy of results in a particular circumstance, phone MDA National for advice.
If an employer or insurer is paying for an examination, there should be a written agreement between the payer and the patient as to who owns the results; and the Radiology practice should be clear about what authorisations are necessary to provide a copy of the results.
What should I document about the consent process?
The Royal Australian and New Zealand College of Radiology’s (RANZCR) Medical Imaging Consent Guidelines provide a good guide to documenting consent:
When obtaining consent at the time of the examination, the form of consent and the manner in which consent is recorded will differ depending on the type of examination, the degree of risk and, in emergencies, whether the imaging is time-critical. The more complex the medical imaging examination or the greater the risks, the more important it is to have formal documentation of the consent process. However, the way in which consent is recorded is left to the individual Radiologist’s judgement.
Implied consent occurs usually with very low-risk procedures such as when consent is implied by a patient placing their hand in an x-ray machine.
Verbal consent involves a discussion about what a procedure will involve and its risks and benefits, allowing a patient to decide if they are happy to proceed. A contemporaneous note of this discussion should be made and kept in the patient’s records.
Written consent provides evidence of what the consent process involved and should be kept in the patient’s records RANZCR’s Medical Imaging Consent Guidelines give the following examples of when written consent should be obtained:
- when the medical imaging examination is complex or has significant risks and/or side effects (e.g. contrast administration)
- interventional procedures: any procedure where the skin is breached, other than IV cannula insertion
- when clinical care is not the primary purpose of the medical imaging examination
- there are significant consequences for the patient’s personal or work life.
What should we be doing to maintain patients’ privacy in the waiting room?
To protect patients’ confidentiality, their details should not be overheard or seen by other people in the waiting room. Options include:
- New patients complete a New Patients Details form in writing rather than having to give details verbally. If a patient has difficulty writing they can be taken to a private room to provide their details verbally.
- Computer screens are away from public view and screen savers are used
- Use of appropriate background music, magazines and/or TV to draw attention away from reception and to mask conversations
- Chairs face away from and are at some distance from the reception desk
- Full names are not called out in the waiting room
- Staff talking to patients on the phone do not repeat personal details provided by the patients
- If conveying sensitive information on the telephone staff make the call in a private location
- Patients are offered a private room for conversation as required.
What steps are required in the management of a patient who:
1. Says they have had an allergic reaction to IV contrast in the past
Previous reaction to contrast media is the most important risk factor of a contrast procedure, and carries a 20-60% absolute risk during subsequent exposure.6 The risk of a contrast reaction should be carefully weighed against the benefit expected from doing the examination. Any other known risk factors should also be taken into consideration. The patient must be warned of the risks and provided with enough information that they can make an informed decision about whether to have the examination. In many instances where the patient has previously had an allergic reaction it will be wise to involve the referring doctor as well.
The RANZCR Guidelines for Iodinated Contrast Administration7 (the guidelines) advise:
- evaluate the nature of the previous reaction and the contrast agent used
- consider a non-contrast study, alternative imaging, or alternative contrast agent.
If it is decided to proceed with the contrast-enhanced study, specific recommendations about the agent and its administration are made in the guidelines.
2. Has an allergic reaction to IV contrast
The guidelines detail specific interventions according to the reaction, ranging from supportive measures for mild urticaria to oxygen, IV fluids and adrenaline for moderate isolated hypotension.
3. Has a severe anaphylactic reaction?
The guidelines contain specific instructions, including the dosage of adrenaline, which is life-saving and must be used promptly.
A Radiology practice which administers contrast should have, in line with the RANZCR standards:
- documented procedures which comply with the current version of the RANZCR contrast guidelines
- a protocol for the management of adverse reactions to contrast, including transfer of a patient to an acute care facility if required
- designated trained personnel who administer intravenous contrast media should also be trained in basic life support including CPR and in advanced life support where possible
- and emergency equipment to support the management of adverse reactions to contrast
- a clearly identified staff member who ensures that resuscitation equipment and drugs etc. are present and in a state of readiness.
How much detail is needed in the medical records?
The Medical Board of Australia’s code of conduct8 states:
Good medical practice involves:
8.4.1 Keeping accurate, up-to-date and legible records that report relevant details of clinical history, clinical findings, investigations, information given to patients, medication and other management
…
8.4.4 Ensuring that the records are sufficient to facilitate continuity of patient care.
The Radiologist’s interpretation of imaging findings has a direct impact on the safety and appropriateness of a patient’s ongoing care. Appropriate documentation in the Radiology report is detailed in RANZCR’s Radiology Written Report Guidelines9 with the content structured by:
- patient demographics,identification details/report status
- history/clinical information
- comparison with prior studies
- technique
- examination type, date and time and quality
- findings
- addressing the clinical question/differential diagnosis
- conclusion/opinion/impression
- recommendations (for further testing, treatment, referral etc)
- discrepancy documentation
- if the report is preliminary and awaiting approval or finalisation by another radiologist this should be stated.
The Radiology Written Report Guidelines also address the format of the report and style of expression.
Proof-reading the report for accuracy before delivery is also crucial. t.
Besides the report, your records should include:
- a copy of the referral
- clinically relevant discussions with referrers (or their staff) and colleagues
- clinically relevant information provided by the patient or their guardian
- consent (documentation of verbal consent, or copy of written consent)
References
- Royal Australian and New Zealand College of Radiologists. Standards of Practice for Diagnostic and Interventional Radiology version 10. Sydney: RANZCR, 2014, p40.
- Berlin L. Communicating Findings of Radiologic Examinations: Whither Goest the Radiologist’s Duty? AJR 2002;178:809-815.
- Royal Australian and New Zealand College of Radiologists, op. cit. pp36-37.
- Finlay AJF, Stewart CL & Parker M. Open Disclosure: Ethical, Professional and Legal Obligations, and the Way Forward for Regulation. MJA 2013;198(8):445-450.
- The grounds for refusing access include:
- Giving access would pose a serious threat to life, health or safety of any individual
- Giving access would have an unreasonable impact on the privacy of other individuals
- The request is frivolous or vexatious
- Giving access would be unlawful
From Office of the Australian Information Commissioner. APP Guidelines Chapter 12: APP12 – Access to personal information. Available at: oaic.gov.au/agencies-and- organisations/app-guidelines/chapter-12-app-12- access-to-personal-information - Thomson KR & Varma DK. Safe Use of Radiographic Contrast Media. Australian Prescriber 2010;33:19-22.
- Royal Australian and New Zealand College of Radiologists. Guidelines for Iodinated Contrast Administration. 2009.
- The Medical Board of Australia. Good Medical Practice: A Code of Conduct for Doctors in Australia. 2010. Available at: medicalboard.gov.au/Codes-Guidelines-Policies/Code-of-conduct.aspx
- Royal Australian and New Zealand College of Radiologists. Radiology Written Report Guidelines 2011. Available at: ranzcr.edu.au/quality-a-safety/program/written-report-guidelines
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