Standards › Standard 50 › Policies
Policy · RAD-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 50.1
At a glance
- Every imaging study that uses ionising radiation is clinically justified before it is ordered (RAD-FRM-001).
- Dose is optimised to the lowest level that gives diagnostic quality.
- Dose is audited each year, and any dose above the reference level is reviewed.
- Cross-refer to the dental radiography policy (DEN-POL-002) for dental studies.
- Stop and get help straight away if: an imaging study with radiation is performed without a recorded justification.
1. Purpose
To make sure every radiation study is clinically justified and its dose kept as low as diagnostic quality allows (50.1).
2. Scope
| Applies to | Clinical and support staff in the hospital |
| Locations | All wards, clinics and departments of the facility |
| When | Whenever the activity described is carried out |
| Does not apply to | Activities covered by another document listed in section 15 |
3. Definitions
| Term | Meaning |
|---|---|
| Clinical lead | The doctor or nurse in charge of the area at the time |
4. Background
Ionising radiation can harm the patient, so each scan must be justified, and the dose kept as low as the result allows. Both are required for every study.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Radiologist | Justifies each study and approves the protocol | Clinical lead |
| Radiographer | Optimises dose on each study and records the exposure | Radiologist |
6. Materials and equipment
| Item | Requirement | Condition |
|---|---|---|
| Records and forms named in this document | Current version | Checked before use |
7. Safety
- Stop and call for help if a patient is at immediate risk. Do not delay urgent care to complete paperwork.
8. Before you start
- Confirm the forms and equipment named in this document are available and current.
9. Procedure
Step 1. Justify.
- Record the clinical justification before the study is ordered (RAD-FRM-001).
Key point: Justified.
Step 2. Optimise.
- Set the protocol to the lowest dose that gives diagnostic quality.
Key point: Optimised.
Step 3. Audit.
- Audit dose each year and review any dose above the reference level.
Key point: Audited.
10. Decision points
- No decision points in this procedure.
11. Special situations
| Situation | Action |
|---|---|
| Out of hours | Follow the same steps. Use the on-call contact on the wall of the area. |
12. Escalation
- Any serious problem goes to the duty clinical lead at once and to the clinical director the same day.
13. Monitoring
| Measure | Target | Frequency | Owner | If not met |
|---|---|---|---|---|
| Studies with a recorded justification | 100% | Monthly | Radiologist | Hold the study until justified |
| Annual dose audit completed | 100% | Yearly | Radiologist | Escalate to the hospital director |
14. Records
| Record | Kept in | Retention |
|---|---|---|
| Record named in this document | Patient record or the area file | the period set by the facility’s records policy years |
15. Training
- Staff are trained in this document at induction and refreshed each year, with a recorded competency check.
16. Related documents
| ID | Title | Use |
|---|---|---|
| RAD-FRM-001 | Radiation justification record | Record |
| DEN-POL-002 | Dental radiography justification and dose optimisation (existing, reused) | Policy |
17. Evidence
| Reference | Note |
|---|---|
| E-006 | ASF Policy Framework v1.2. Adapted. |
| E-009 | ASF Expert Committee consensus. |
18. Change history
| Version | Date | What changed | Approval |
|---|---|---|---|
| 1.0 | the date of approval | First version | set Expert Committee approval |
E-learning for this document
References
- Accréditation Sans Frontières (2026). ASF Policy Framework v1.2. (E-006)
- Accréditation Sans Frontières (2026). ASF Expert Committee consensus on Standard 1. (E-009)