Developed in response to: To reduce diagnosis and treatment delays in selected patients by referral to the imaging department by nonmedical

Transcription

1 Imaging Referrals by Non-Medical Practitioners Operating Policy Type: Policy Register No: Status: Public Developed in response to: To reduce diagnosis and treatment delays in selected patients by referral to the imaging department by nonmedical practitioners. Contributes to CQC Outcome 4 Consulted With Post/Committee/Group Date Jane Renals Imaging Services Manager November 2016 Patricia Clinch Radiation Protection Advisor November 2016 Professionally Approved By Dr Railton September 2016 Version Number 3.0 Issuing Directorate Radiology Ratified by: DRAG Chairmans Action Ratified on: 24 th November 2016 Trust Executive Sign Off Date December 2016 Implementation Date 25 th November 2016 Next Review Date October 2019 Authors/Contacts for Information A. Francis and S. Ridgwell Policy to be followed by (target staff) All MEHT staff Distribution Method , Intranet &Website Related Trust Policies (to be read in Standard Infection Prevention conjunction with) Hand Hygiene Consent Policy Patient Identification Policy SOP - IR(ME)R Schedule Procedure number 2 (ii) - Referrals Procedure for requesting Medical Exposure. SOP - IR(ME)R Schedule Procedure number 2 (ii) -Justifying a request. SOP - IR(ME)R Schedule Procedure number 4 - Procedure of LMP policy. Document Review History Version No Authored/Reviewed by Active Date 1.0 Andrea Francis/Sarah Ridgwell Andrea Francis/Sarah Ridgwell Andrea Francis/Sarah Ridgwell 25 November

2 Index 1. Purpose 2. Background 3. Equality and Diversity 4. Scope 5. Associated Polices and Procedures 6. Roles and responsibilities 6.1 All Parties 6.2 Primary Care Trusts 6.3 Radiology Service Manager and Trust Radiation Protection Committee at MEHT 6.4 Clinicians 6.5 Service Mangers/Practice Manager 6.6 The Radiology department at MEHT 6.7 Referrer 7. Referral process 8. Consent 7.1 General Principles 7.2 Categories of referral 9. Interpretation 10. Education and Training 11. Clinical Guidelines 12. Radiology Referral agreement 13. Risk Management 14. Audit 15. Infection Prevention 16. References Appendix 1 Referrers Procedure for requesting Medical exposures, V.1.1 Appendix 2 Pregnancy Status Policy V.1.1 Appendix 3 Speciality Scope of Practice Appendix 4 Individual Referrer Agreement Appendix 5 Non-medical Referrer Imaging Request Pathway Appendix 6 MR Operation Policy Appendix 7 MR pregnancy Policy 2

3 1.0 Purpose 1.1 To provide a mechanism for appropriately qualified staff to refer patients for radiological examinations. 1.2 To provide supporting guidance related to the scope of the role and the consequential education and training requirements. 2.0 Background 2.1 The justification for non-medical health care professionals referring to radiology must be that patient care will be improved by the practice and reflect current accepted practices. 2.2 The NHS Plan included many initiatives to modernise the way in which care is delivered. This includes broadening the scope of practice for many health care professionals and referring patients for diagnostic imaging is just one example. One of the 10 key roles for nurses includes referral for diagnostic investigations. This has not been restricted to nursing, allied health professionals (AHPs) are also developing their roles, and as such, co-ordination of these roles and relevant education is required. 2.3 Healthcare Professionals may be in positions where their expanding roles require them to provide a comprehensive service for patients and will require access to imaging to meet this need. It is often appropriate that a person other than a doctor refers for radiological examinations, this may be to provide an efficient service, or because the person responsible for initial patient management is another health professional. 2.4 Appropriate initial and continuing education must underpin all role development and training programmes. A level of responsibility for the education of staff lies with the clinician from whom the role is delegated and the radiology department, which will take responsibility for the areas of development related to radiation protection. 3.0 Equality and Diversity 3.1 Mid Essex Hospitals is committed to the provision of a service that is fair, accessible and meets the needs of all individuals. 4.0 Scope 4.1 This policy covers staff employed by Mid Essex Hospitals Service (MEHT) NHS Trust and staff employed by General Practitioners contracted by the CCG. 4.2 All non-medical professions registered with the nursing and midwifery council or health professions council are included within in the scope of this policy. 4.3 All referrals for examinations performed by the radiology department are included within this policy, both those involving the use of ionising radiation and those not, such as Ultrasound or MRI. 3

4 4.4 The Specialty Scope of Practice Agreement (Appendix 3) is designed to identify for Mid Essex Hospital Services NHS Trust the degree to which appropriately trained non-medical health professionals will refer patients for examinations. 5.0 Associated Policies and Procedures 5.1 This policy should be read in conjunction with The Standard Operation Policy Referrers Procedure for requesting Medical exposures, V.1.1. see appendix Services and practices which implement referral for radiology by non-medical staff should provide documentation to establish the rationale for this development in the form of clinical guidelines (see section 10). This policy should therefore be read in conjunction with these specific clinical guidelines. 5.3 MR Operation Policy and Pregnancy policy ( see appendix 6 & 7) 6.0 Roles and responsibilities 6.1 All Parties All parties must be certain that the member of staff is suitably qualified, experienced and competent to carry out the responsibilities delegated to them. In addition the following roles and responsibilities apply. 6.2 Primary Care Trusts Staff will be supported to develop their role through the Trusts clinical governance and continuing professional development arrangements. 6.3 Radiology Service Managers and the MEHT Radiation Protection Group To maintain a central list of authorised referrers To approve the delegation and referral agreements To ensure authors undertake a regular review of this policy To provide an educational programme covering Ionising Radiation (Medical Exposure) Regulations (IR(ME)R 2000, 2006, 2011) by approved Radiation Protection Advisors or Radiation Protection Supervisors, where the referrer wishes to refer for ionising radiation procedures To undertake a yearly review of authorised non-medical referrers to ensure that they are still employed within the Trust and are still required to refer in their current role. 6.4 Clinicians When delegating a role, the clinician retains full clinical and managerial responsibility for the patient. The clinician shares responsibility for proper performance of the task not only with the delegated member of staff but also that person s employer Responsibility for the education of staff in relation to their role in the clinical areas lies with either the clinician from whom the role is delegated for staff employed by a GP 4

5 practice or from the appropriate director responsible for the service provision for staff employed by the Trust. 6.5 Service Managers/Practice Managers Identification of any current practice covered by this policy Maintain a list of approved referrers in their clinical area Ensure changes or additions to the referrers list are submitted and that a specimen signature is supplied to the radiology department, prior to referrals commencing Ensure appropriate education and training is undertaken by relevant staff. 6.6 The Radiology Department at MEHT The radiology department will take responsibility for specific areas of development indicated in section To ensure regular audit is undertaken. 6.7 Referrer To ensure that initial and continuing education and training is undertaken to ensure competence in their role To undertake regular audit of their practice. 7.0 Referral Process 7.1 General Principles It is the responsibility of the referrer to provide sufficient clinical information to enable justification and clarify expectations of the examination. Examinations must be justified under the IR(ME)R (UKAS Guidelines in the case of ultrasound referrals and MHRA guidelines for MRI) The radiology department (Radiographer, Sonographer or Radiologist) will refuse any referrals that are considered inappropriate All referrals must be legible and should indicate clearly the name, role of the referrer e.g. Nurse Practitioner, Cardiac Nurse and department/gp practice The referrer must complete all of the fields on the request form. It is inappropriate for one health professional to complete part of the form and another to sign it since the Radiology Department must be sure that the person completing the request holds relevant clinical assessment skills and authorisation to be able to justify the decision Referrals should indicate the region for examination and appropriate clinical information; the most appropriate examination will be undertaken in line with the radiology standard protocols. 5

6 7.1.6 If any referrer is in doubt as to whether an investigation is required, or which examination is best, they should discuss the case with an appropriate medical practitioner, Radiologist or Radiographer, prior to referral Notice should be taken of previous relevant examinations in order not to expose a patient to ionising radiation unnecessarily All referrals must be completed in line with the MEHT Standard operational policy Pregnancy Status Policy V.1.1, Appendix It is the referrer s responsibility to ensure the patient does not have any devices that may contraindicate the procedure taking place. If any implants or devices have been identified, documented evidence of the make, model and serial number, position in the patient and the date of implant should be provided. Please note there are many devices that are incompatible with MRI scanning. Advice should be sought prior to completing a referral if it is unclear whether the particular patient is suitable for the radiology modality. 7.2 Categories of referral There are currently two categories of referral for imaging, with an acknowledgement of the different levels of responsibility for patient care, however both carry the same level of responsibility for the referral process. The categories are: Referral under protocol i.e. under direction from doctor in notes/specific pathway. Assessment of patient and referral for imaging based on clinical signs e.g. Nurse Practitioner It is recognised that there are different requirements for education and training relevant to the clinical role and these will have to be met prior to commencing referrals. Further details are provided in section Consent 8.1 It is the responsibility of the referrer to ensure that informed consent is obtained for the procedure they are requesting. This includes where appropriate discussing the risk vs. benefit of an examination. 8.2 This does not absolve the radiographer/sonographer from their responsibility with regard to patient consent. 9.0 Interpretation 9.1 The Royal College of Radiologists Guidelines indicate that all radiology procedures should be formally reported. This clinical report may be issued by a Radiologist, Sonographer or Reporting Radiographer dependent on the procedure. In some cases this may be delegated to Non-Radiology staff Education and Training 10.1 Specific education relevant to their own area of practice must be undertaken by all staff in order to support their role development. 6

7 10.2 All non-medical referrers must complete PAS training so that imaging requests can be electronically generated. Non-medical referrers working in departments which currently use paper request forms (i.e. Orthopaedic Out-Patients, Accident and Emergency) may continue to use paper request forms until their department converts to electronic requests Radiation awareness training sessions can only be delivered by Radiation Protection Supervisors or Radiation Protection Advisors. These can be booked by contacting the Radiology A&C Manager on ext Radiation Protection This training is relevant only for those referring for imaging procedures involving ionising radiation and will encompass the following: Potential hazards in irradiating patients and an understanding of the associated regulations. Contraindication to referral for imaging and the risk of unnecessary exposure to ionising radiation. Radiation protection of high risk groups e.g. females of child bearing age General Education This is relevant to all staff who refer regardless of the category of referral and will encompass the following: The role of the Referrer, Operator and Practitioner. Indications for referral for imaging. The mechanism and importance of Audit Referral guidelines and completion of referral forms. Communication with the patient of the need (or not) for radiological examination and associated issues. Consent 10.6 Clinical Education This must be appropriate to the category of referral, and should be agreed within the delegating clinical director/gp and documented in the individual referrer agreement The education may be delivered locally or as part of a recognised post registration programme, but must encompass all of the details of the role and responsibilities Development of Clinical Guidelines 11.1 For all areas clinical guidelines should be developed to ensure the proposal has the full support of the Trust and that issue of patient safety and staff development have been considered The following should be considered within the guidelines: Benefit to the patient of the initiative 7

8 Number of patients expected to be referred by non-medical staff per month under this initiative. This should also indicate whether this replaces referrals from the delegating clinician or whether this is a new initiative Specific examinations to be referred including specific inclusion or exclusion for age of patients Identify which categories of patients are to be referred. (This should include the expectations of the service e.g. orthopaedic clinic Staff involved in o Referring o Delegating Proposed commencement date Who is responsible for the initial interpretation of the resultant images? (This includes recording the evaluation in the clinical records) 11.3 The guidelines must identify the education and training to be completed by referrers Radiology Referral agreement 12.1 A Radiology Referral Agreement must be completed for all non-medical referral protocols. This may affect individuals or groups of individuals dependent on the clinical area. It is comprised of 2 parts: a Speciality Scope of Practice and an Individual Referral Agreement. The pathway to enable the agreement to be reached can be found in Appendix 5 - Radiology Referral Agreement Pathway Speciality Scope of Practice (Appendix 3) The speciality scope of practice is an agreement between the radiology service and the delegating clinician/gp, and should be completed with reference to the points in Section 11, using the Speciality Scope of Practice form in Appendix C The agreement will identify the scope of practice i.e. the professionals covered under the scope of Practice, department, the examination(s) wishing to be requested and under what circumstances, exclusions, benefit to the patient of the scheme and initial reporting arrangements for images Once completed, the Speciality Scope of Practice form should be returned to the Radiology Governance Lead. This will then be reviewed by the Imaging Services Manager, the Radiologist Lead and relevant Radiology Clinical Leads The delegating clinician/gp must sign the Speciality Scope of Practice form and will be responsible for delegating the referral process Individual Referrer Agreement (Appendix 4) Confirmation must be given that the individual is working to approved clinical guidelines and has received supervised clinical training from the delegating clinician Confirmation must be given that the individual has received the IR(ME)R training delivered either within the Trust or other certificated equivalent training on Radiation Awareness, if appropriate to the referral Responsibility as a referrer cannot be transferred between individuals and any new appointments must follow the guidelines in place for the speciality and an Individual 8

9 Referrer Agreement must be completed and submitted to the Radiology Governance Lead The Individual Referrer Agreement must be completed electronically, signed and sent as an attachment via to the Radiology Governance Lead. This will then be reviewed by a Clinical Lead who will authorise or decline the application Any agreement which is declined by the Radiology Department will be returned to the applicant with a full explanation as to how this decision was made The Individual Referrer Agreements will be stored electronically on the Radiology S:Drive The Radiology Department can terminate referral rights at any time, either in whole or for any named individual for any persistent abuse of the agreement Risk Management 13.1 In the event that there is a query with the request or individuals operate outside of their agreed Scope of Practice, there will be an initial consultation with the individual concerned In the event of a disagreement, the radiographer has the right to refuse a request and ask for a medical opinion. Any such incidents will be documented and investigated via MEHT s Datix Web system Audit 14.1 Staff must regularly audit their practice 14.2 Joint Audit between clinical specialities and radiology with reference to referrals is encouraged Examples of audit may include: Radiology referral rates. Number of referrals made with significant abnormality. Accuracy of interpretation Infection Prevention 15.1 All staff should follow Trust guidelines on infection prevention control by ensuring that they effectively decontaminated their hands before and after each patient contact References MEHT Standard Operational Procedures :- MEHT IR(ME)R Schedule Procedure number 2 (ii) - Referrals Procedure for requesting Medical Exposure. MEHT IR(ME)R Schedule Procedure number 2 (ii) -Justifying a request. MEHT IR(ME)R Schedule Procedure number 4 - Procedure of LMP policy. 9

10 College of Radiographers (2002), Statements for Professional Conduct, College of Radiographers: London. Department of Health (2000), Ionising Radiation (Medical Exposure) Regulations, Department of Health: London. Department of Health (2000), NHS Plan A plan for investment, A plan for reform, Department of Health: London. Department of Health (2002), PL CNO (2002)5 (Implementing the NHS plan - ten key roles for nurses), Department of Health: London. Department of Health (2003), 10 key roles for Allied Health Professionals, Department of Health: London. Department of Health (2000., 2006, 2011), Ionising Radiation (Medical Exposure) Regulations (and subsequent amendments), Department of Health: London. Kirklees NHS Primary Care Trust (2007), Non-medical Referral to Radiology at the Mid-Yorkshire Hospitals NHS Trust or Calderdale and Huddersfield NHS Foundation Trust Patient Dose Reduction in Diagnostic Radiology 1990 (NRPB/Royal College of Radiologists Documents of the NRPB, Vol 1, No 3, 1990). Safety Guidelines for Magnetic Resonance Imaging Equipment in Clinical Use. Nov /Safety_guidelines_for_magnetic_resonance_imaging_equipment_in_clinical_u se.pdf 10

11 Appendix 1 Referrals Procedure for requesting Medical Exposures Purpose The purpose of this procedure is to ensure that all persons making referrals for medical exposures are entitled to do so by MEHT. Referrals will be accepted from the following Medical groups:- 1 All permanent registered medical practitioners employed by the Trust 2 All locum registered medical practitioners employed by the Trust 3 All Mid Essex GP s registered with the General Medical Council 4 All Dental Practitioners registered with the General Dental Council 5 All medical practitioners, registered with the GMC referring patients under the Choose and Book system. 6 The list of approved referrers can be found on the radiology s drive. Referrals will also be accepted from registered Health Care Professionals (HCP s) and other approved referrers 1 The x-ray referral guidelines procedure must be followed and approved. This is located in the radiology s drive. 2 Once the form is approved, the named referrer is added to the approved list on the radiology s drive. The original copy is kept with the RIS radiology Manager. 3 The referrer is then given access to the relevant IT requesting systems. Referrals will be made within the current Royal College of Radiology guidelines and also within any local guidelines. Each specialist group will refer only to their agreed protocols. Duties of the referrer are: - 1 To supply the correct details for patient identification, using a 3 point ID check. 2 To supply sufficient medical data to enable the practitioner to justify the exposure, including checking previous examination history. 3 To assess the pregnancy status of female patients between the age of In the case of other non-medical referrers - They must follow the local procedures/protocols as agreed by Radiation Protection Committee and the Referrers Clinical Director. 5 Contact details of the referrer must be provided on the request. All referrers not using the recognised secure computer systems (Hospital internal or Choose and Book) must be able to provide a sample signature if requested by the Trust. 11

12 Appendix 2 PREGNANCY STATUS POLICY Departmental Policy: 28 Day rule (low dose) 10 Day Rule (high dose) All X-ray instruction literature asks female patients to inform the Department immediately if they think they might be pregnant. Introduction It is the ultimate responsibility of the operator to enquire, prior to any medical exposure whether a female of reproductive capacity could be pregnant. In the case of nuclear medicine procedures an additional enquiry shall be made to establish if the patient is currently breastfeeding. In this procedure, a female of reproductive capacity is taken to be someone between years of age. Procedure When a female of reproductive capacity presents for: An exposure in which the primary beam may irradiate an area between the diaphragm and the knees, or Cardiac interventional procedures, or Any procedure involving radiopharmaceuticals, The operator shall ask if there is any possibility that she might be pregnant. For X-ray procedures, the operator shall record the patient s responses on the CRIS system by rescanning the request form / safety form with the No risk of pregnancy stamp present on the request along with the patient s signature. For cardiac angiography procedures, the patient s notes will be stamped directly and signed before the start of the examination. For nuclear medicine procedures, the operator shall also ask if the patient is breastfeeding. If the patient is under the age of 16 years, this question can be asked discretely where possible. Question: Answer: Answer: Is there any possibility that you may be pregnant? NO The patient to sign the form, ICP (Cardiac) or checklist sheet in no risk of pregnancy, and proceed with examination. Anything other than NO. Follow instructions below. 12

13 Patient definitely pregnant or pregnancy cannot be excluded LOW foetal dose procedure (foetal dose <10 mgy) [Most X-ray and nuclear medicine examinations fall into this category of foetal dose except for those in the section below included in the high foetal dose procedures.] The practitioner shall review the justification and consider rescheduling the examination or using alternative investigations. The practitioner shall explain that the risk to the unborn foetus is acceptable and that the examination can proceed. The patient may opt to defer the examination. If the patient wishes to proceed, the request should be stamped with the stamp which states patient pregnant happy to proceed along with the patient s signature and this is then re-scanned into the CRIS system. Before the procedure can be undertaken, the patient shall be consented by the practitioner. For interventional procedures (including those done under a general anaesthetic), the patient shall sign the Trust Consent Form. Patient definitely pregnant or pregnancy cannot be excluded HIGH foetal dose procedure (foetal dose 10 mgy) [High foetal dose examinations include CT of the pelvis, pelvis-abdomen and kidneyureter-bladder, interventional examinations, myocardial SPECT and PET/CT whole body scan.] The practitioner shall review the justification. When pregnancy cannot be excluded, the practitioner shall explain why the examination has to be postponed and shall re-book it during the first 10 days of the patient s menstrual cycle. If the examination cannot be delayed, the foetal dose shall be kept to the minimum consistent with the clinical requirements. Details of the exposure shall be recorded both on CRIS and via the patient pregnant form and an estimate of the radiation risk to the foetus shall be determined by a Trust Medical Physics Expert. The foetal dose and risk shall be recorded in the patient s notes. Breastfeeding patients (nuclear medicine procedures only) The practitioner shall review the justification. If the procedure is undertaken, the operator shall seek advice from a Trust Medical Physics Expert in relation to precautions that the patient should take subsequently. Patients who are unable to answer for themselves A radiologist, in conjunction with the referring clinician if necessary, shall make a judgement on behalf of patients who are unable to answer for themselves (e.g. those without capacity). An interpreter shall assist if the patient s command of English is poor. Pregnancy shall be assumed if it cannot be excluded. Procedure when X-raying Pregnant Women Exposures can be justified during pregnancy in emergency trauma/ surgery,? Pulmonary Embolus or where delay could be detrimental to the patient s health. For all plain film examinations, lead protection will be provided when appropriate. 13

14 ALL EXPOSURES MUST BE KEPT TO A MINIMUM RECORD OF JUSTIFIED EXPOSURES MADE DURING PREGNANCY PATIENT DETAILS NAME DATE OF BIRTH REG NUMBER Estimated Delivery Date / GESTATION AGE REFFERER PRACTITIONER EXAMINATION ROOM. NUMBER OF FILMS TAKEN... PROJECTIONS AND EXPOSURE FACTORS PROJECTION KVP MAS DAP FFD FLUORO TIME Please place fully completed form in the patients hospital notes Procedure when a patient discovers she is pregnant after undergoing a radiological examination. Please record the patient s details and pass the information to an RPS who will then contact the patient. 14

15 Appendix 3 Speciality Scope of Practice This agreement is designed to clearly identify for Mid Essex Hospital Services NHS Trust the degree to which appropriately trained non-medical health professionals will refer patients for examinations. This agreement is recognised by the Trust as appropriate referral practice. Non-Medical Radiology Referral Agreement for (please state group or Job Role not individual referrers name) Scope of the agreement Health Professionals covered under Agreement: Referring Department/GP Practice: Please insert telephone number Examinations covered & under what circumstances (please add rows as necessary): Examination Valid reasons for Referral/Justification Page 1 of 3 15

16 Exclusions e.g. paediatrics / pregnant females: Benefit to the patient from the initiative: Reporting arrangements for films: Page 2 of 3 Before an individual can participate they must have completed all appropriate training, including an IR(ME)R Radiation Protection Course, as stated in the Non-Medical Referring Policy for ionising radiation procedures, or an MRI presentation as appropriate. Only fully completed valid request forms will be accepted, showing the examination required, relevant clinical history and symptoms. 16

17 The justification for all referrals remains with the practitioner as per IR(ME)R regulations (usually the radiographer or sonographer). Any discrepancy as to the initial request will be directed in the first instance back to the referrer. Standard views will be taken of each body part and additional views at the discretion of the practitioner. Signatories I, the undersigned, approve the implementation of this agreement as specified above. Radiologist Lead: Print name: Imaging services Manager: Print name: Delegating Clinical Director or GP: Print name: Agreement Date: Page 3 of 3 17

18 Appendix 4 Individual referrer agreement This protocol is designed to clearly identify the individuals allowed to work within this referral agreement. Non-Medical Radiology Referral Agreement for Part one. To confirm the suitability of the NHS professional with regard to experience and competence within their speciality. Name of referrer: Job title: Registration/PIN number: Specific Qualifications/Role including Banding: Referring department: Signature of referrer: Signature of manager: (Confirming suitability) Print name: Signature of delegating clinician: Print name: Designation: Date: Page 1 of 2 18

19 Part two: Confirmation that the above named individual has attended the radiology services IR(ME)R training session or alternative (please state) if appropriate. Date attended: Signature of trainer: Print name: Part Three : Authorisation to Refer by MEHT Radiology Department Yes: No: (please provide comments below) Name: Signature: Position: Radiologist Lead Date: Page 2 of 2 19

20 Appendix 5 Radiology Referral Agreement Pathway Stage 1 - Need for Non-medical Referral for imaging established Stage 2 - Submit completed Speciality Scope of Practice (Appendix i) form to Radiology Governance Lead via an attachment in accompanying . nb. Form must be signed by Delegating Clinician Stage 3 - Scope of Practice reviewed by Imaging services Manager, Clinical Director and Clinical Leads Stage 4 - Not Agreed Form returned to author with comments via Stage 5 - Agreed Signed Scope of Practice returned via to author Stage 6 - Individual Referrer Agreement (Parts 1-3) to be completed by those wishing to refer. Submit to Radiology Governance Lead via attachment in accompanying nb. Applications will be automatically rejected if any of parts 1-3 have not been completed. Stage 7 - Review by Radiation Protection Supervisor / Clinical Lead Stage 8 - Application declined Form returned by to author with comments Stage 9 - Application agreed Copy signed, scanned and sent to: a. The applicant authorising referrals with immediate effect b. Radiology S.Drive Where a Speciality Scope of Practice already exists, the individual wishing to refer starts the process at Stage 6 20

21 Appendix 6 S:\RadiologyDept\ Radiology\Departmen Appendix 7 S:\RadiologyDept\ Radiology\Departmen 21