Every Employer is required to establish and maintain procedures that define how every aspect of his operation (apart from matters of professional judgement) that may affect a patient's exposure to ionising radiation, is carried out. These generic draft procedures cover most of the requiremets for chiropractic radiography. The apparent convolutions are due tot he fact that IR(ME)R requires any person acting in more than one capacity (as employer, referrer, practitioner or operator) to carry out the all the duties applicable to each capacity. For most single-handed practices "this means you".
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1. The Employer, for the purposes of the Ionising Radiations Regulations, is .......................... Any registered chiropractor employed in a direct or locum capacity, is entitled to act as Referrer, and if qualified in chiropractic radiological examination, as Practitioner and Operator. The names of such employees, and others entitled to act in specific capacities, are listed in an appendix to these Procedures. The following procedures are the Employer's Procedures required by Schedule 1 of the Ionising Radiation (Medical Exposure) Regulations 2000.
2. The Employer's referral criterion is that any patient who in the opinion of the Referrer is likely to benefit from x-ray examination may if he consents be referred to the Practitioner for x-ray examination.
3. Referrer: Make written clinical notes in the patient's record sufficient to permit yourself in your capacity as Practitioner to justify any x-ray exposure which in your capacity as Referrer you may consider appropriate to the patient's treatment.
4 Practitioner: Consider the data which you have provided to yourself and decide whether in the light of the specific objectives of the exposure, the characteristics of the patient, the total potential benefits to society and the patient, the individual detriment that the exposure may cause, and the efficacy risks benefits and availablility of alternative techniques, whether to justify the exposure.
5. Practitioner: Ask and record the date of the last menstrual period of any female patient, and invite her to sign the declaration that she is not pregnant. If she says she is pregnant, or is not certain, explain the "28-day rule" and invite her to sign consent to x-ray examination if in your opinion the benefits of such examination will outweigh the risks arising from it. A patient who has missed a period may not be x-rayed in this practice unless she signs the delaration that she is not pregnant. A patient who is unwilling to sign the declaration or consent may not be x-rayed in this practice.
6. Whilst there is no statutory requirement to record the Practitioner's justification, the Employer requires the Practitioner to use the "tick list" or write in the reasons for proceeding to x-ray examination, on the patient record form, for statistical purposes.
7. Practitioner: If the exposure is justified, authorise the exposure by signing the appropriate box on the x-ray record form.
8. Practitioner: Ask the patient to check that his/her name, date of birth and address are correctly recorded on the x-ray record form. Hand the form to the patient to give to the Operator, if you are not the Operator.
9. Operator: Refer to the exposure chart to select appropriate technique factors, record the projection and factors for each exposure in the journal against the patient's name, and initial the entry. Standard projections used in this clinic are referred from the textbooks held in........................................................ Optimise each exposure in keeping with good professional practice regarding positioning collimation and patient instruction.
10. Operator: Ensure that the patient's name and date of birth, exactly as written on the x-ray record form, and the date of the exposure, are recorded on every film.
11. Operator: Ensure that the film stock is compatible with the screens in use and is in date; that the chemicals are properly stored, in date, and prepared according to the manufacturer's instructions; and that the processor is cleaned and maintained according to the manufacturer's schedule, adequately warmed up and cleaned before processing any clinical films, and is subjected to regular quality control.
12. Operator: Process films immediately after they are exposed. Reload the cassettes and replace them correctly.
13. Operator: Use pre-exposed test films as directed, to test the processor. Initial, date and file each test film. If the test film is not within the normal range, you must prevent further use of the x-ray equipment, investigate, correct and repeat the test. Do not allow anyone to process any clinical films until you are satisfied that the processor is working correctly. If in doubt, consult the Radiation Protection Supervisor named in the Appendix.
14. Operator: Hand all the processed films to the relevant Practitioner as soon as possible, including any rejects.
15. Practitioner: Read and report every film. "NAD" or "Normal" is unlikely to be true in the case of any patient presenting for chiropractic examination and treatment. If there is No Visible Contraindication to manipulative treatment and no other outstanding pathology to report, record "NVC" as a minimum. Sign and date the report.
16. Practitioner: medico-legal and other "third party" referrals may be accepted from Referrers who have established specific contracts with the Employer. The terms of each such contract are held by the Employer to whom reference must be made if the Referrer is not familiar to you.
17. Practitioner and Operator: third party referrals are considered to have been justified and authorised by the Referrer acting in the capacity of Practitioner but good practice requires that you should carry out relevant parts of these Procedures from 5 onwards and record your actions.
18. Practitioner: Once a month, review the Operator's journal and check whether exposure factors for similar projections of similar patients have altered from those delivered a month and a year earlier. If not, it may be presumed that patient doses remain in line with the diagnostic reference levels (DRLs) for this practice. The DRLs adopted are those set out in the current edition of the British Chiropractic Association's Guidance Notes. These are expected not to be exceeded when good and normal practice is applied. If you suspect that doses have increased, contact the Employer or the Medical Physics Expert whose name appears in the Appendix to these Procedures.
19. Operator: Report any suspected malfunction or irregularity in equipment or materials to the Employer immediately.
20. All personnel: The most significant cause of excess patient dose in hospital practice is "lost films". Do not permit any person to remove original films from the practice without signing an explicit receipt with sufficient detail to transfer liability to that person. Preferably, give the films to the patient rather than store them.