Microsoft word - methodology.doc

Akademiska sjukhuset University Hospital Uppsala Revised 2003 10 20 / HJ Version No 16 Example
Checklist for description of methods

Parameters to be checked and if appropriate for the respective method,
filled in according to local organisation and agreements.
More parameters can be included if the local organisation demands. It is
also possible to refer to general guidelines in various areas if appropriate.
This may be the case for certain methods as CT, Ultrasound, MRI etc
However, it is important that there are description of methods for each
examination room (equipment, laboratory)
Principle: Description of methods for each examination room (equipment,
All description of methods follow the same structure (checklist) which makes it more easy to read. Otherwise there can be free text Present description of methods can be updated according to this structure Publication should be made on the department´s intranet and printed Available at each examination room Responsible for this is :……………………
The head of the department is responsible for organising the production
including follow- up of description of methods
Separate parts of this can be delegated according to ge local organisation,
e.g. for CT, MRI, Ultrasound, Interventions etc.

Responsible person for each examination room is defined
sible for
Suggestion: 1. Responsible nurse for each examination room

2. Responsible for method
medical physics
medical technique
3. The head nurse confirms the list
4. The head of the department confirms the organisation
5. Group meetings for a particular method, etc
5. One person responsible for typing
6. All methods are documented together

7. Weekly meeting between to follow the work – according to local org.
8. Methods can be written into a database if available

Version No.
Replaces No. Valid from
Valid until
Expedited by (name)
Confirmed, signed

Checklist to be locally adapted at the particular hospital and

Medical history and
clinical questions to be
answered from the
procedure to be

Quality control of
justification of the
Necessary patient

information from the
patient´s physician
Is the patient informed by
the referring department
about any special
Necessary patient

information from
radiology department.
Is the patient informed by
the readiology department
about any special
Ev. WIPS-journal

-Wellbeein-Intervention-Prevention-Safety Identification of the
Preparations to be

performed at the
examination room or
radiology department
Preparations to be

performed at other
institution or departmen
Equipment, special

utenciles etc

- known allergy
- other information of importance
- procedure if exceeds norm - has increased during the last 6 days
See special general
information on pages: …

Data only relevant for the
particular procedure to be

Qualification needed to
execute the procedure –
- physician
- nurse
- other competencies
Documentation if relevant
- expedition

- exposure data
- criterier for correct
- image quality
- documentation
- cleaning
- etc
Referral to any general

methodologica description
for examination with/of.

Creatinin level
? Diabetes
? Metformin administration
Decision about the examination
procedure if the creatinin level
exceeds norm or if on Metformin
treatment; when was treatment
Type of contrast
Amount of contrast
Administration at the ward
Administration at radiology dpt
Sequencies / coils / etc. MR
Method / CT /

Quality control of the
Immediate information to
Emergency department,
Patient´s physician,
Operation theatre or other
necessary actions to be
performed on an
emergency basis, reading
from soft copies
Image documentation,

hard or soft copies, etc
Special care procedures

after any radiology
intervention or
Information to the

receiving department
caring for the patient after
the radiology department.
Responsibilities regarding
care for the patient during

the procedure transport
and after

Special document for
Qualification needed to

execute reading of soft or
hard copies of any related
examination or other
Contents of the report

- immediate report
to referring
department in case
of medical

- type of report;
Acute, urgent
- form of report;
verbal, telephone,

- Documentation of
the report
Quality control of the
- second reading by
2:d radiologists
- System to inform
referring unit in
case of change of

- System to inform
1:st reader in case
of change of report

Quality control of RIS and
PACS digital function
including archiving of

Other protocols,
e.g. Trauma, Intervention,
Angiography etc protocol

Medical complications
Risks for mistakes
Incident and accident reports if deviations from normal routines are observed by anyone involved in the procedure Accident risks


Radiation protection
General information
Use your local recommendations
Fertile female
At the ages 15 – 45 years shall be asked if they may be pregnant and handled according to the
official regulations by ………………………….
The request form shall be signed confirming that the patient has been asked about the
possibility of being pregnant
Shielding of the gonads
Men under 50 years of age shall be protected by shielding if the testes are located in the
primary beam or less than 5 cm from the margin of the radiated field unless there is a risk that
diagnostic information will be lost
Shall be used if possible and relevant
Effective dose, normal examination
The effective dose at a particular examination for a normal patient is calculated to
xx mSv (male and female respectively)
Reference dose

The reference dose prescribed by the Radiation Protection Authorities for this particular
radiology procedure is xx mSv (KAP = xx Gy*cm²). (The reference dose is the mean dose for
male and female)
Other radiation protective measures to be taken
At this examination, the registered patient dose shall be documented for:

If the skin dose exceeds xx Sv (corresponding KAP-value), the referring physician shall be
informed that a skin reaction may occur during the following days as a result of the radiation
dose received by the patient during the radiology procedure performed.
Rules for approximation

> 5 mSv
approximation to the higher full mSv, ex 5,5 = 6 mSv approximation to the higher half mSv, ex 3,5 = 4 mSv 0,1 - 2 mSv approximation to the higher 1/10 mSv, ex 0,39 = 0,4 mSv < 0,1 mSv


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