Standards › Standard 50 › Policies
Policy · ARC-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 50.6
At a glance
- Imaging studies and reports are kept for the period required by law and the standard.
- Each study can be found and retrieved for comparison with prior studies (ARC-REG-001).
- Studies are archived in a way that keeps practical retrieval possible.
- Retrieval is tested at the set interval.
- Stop and get help straight away if: a prior study cannot be retrieved for comparison when it is needed.
1. Purpose
To make sure imaging studies and reports are kept and can be found for comparison when needed (50.6).
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
Images and reports are needed for comparison, for follow-up and for the law. Keeping them for the required period, and finding them when asked, is part of safe imaging.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Radiology manager | Owns the archive and the retention period | Clinical lead |
| Radiographer | Retrieves prior studies when requested | Radiology manager |
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. Retain.
- Keep each study and report for the required period.
Key point: Retained.
Step 2. Archive.
- Archive each study so it can be retrieved by patient and date.
Key point: Archived.
Step 3. Test retrieval.
- Test retrieval at the set interval, and record it (ARC-REG-001).
Key point: Tested.
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 |
|---|---|---|---|---|
| Prior studies retrieved on request | 100% | Monthly | Radiology manager | Escalate to the clinical lead |
| Retrieval tests completed on schedule | 100% | Quarterly | Radiology manager | Repeat the test within 7 days |
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 |
|---|---|---|
| ARC-REG-001 | Image retrieval test register | Register |
| REC-FRM-002 | Records audit tool (existing, reused) | Form |
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)