Standards › Standard 31 › Plans and templates
Plan · DEN-PLN-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 31.9
At a glance
- The clinic has a written radiation protection programme, reviewed every 12 months.
- Each X-ray unit is checked for dose and performance on the schedule (DEN-REG-003).
- Staff who take radiographs are monitored where the programme requires it.
- The programme is reviewed after any incident.
- Stop and get help straight away if: an X-ray unit is used with no dose or performance check on record.
1. Purpose
To make sure the clinic protects patients and staff from radiation through a documented and reviewed programme (31.9).
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
Staff who take X-rays are exposed to radiation every day. A radiation protection programme, with shielding and dose monitoring, keeps that exposure within limits.
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Radiation protection lead | Owns the programme and its schedule | Clinical director |
| Clinical director | Approves the programme and its review | Medical director |
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. Write and approve.
- Write the programme against the national requirement and approve it.
Key point: Approved.
Step 2. Check equipment.
- Check each unit on schedule and record it (DEN-REG-003).
Key point: Checked.
Step 3. Review.
- Review the programme every 12 months and after any incident.
Key point: Reviewed.
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 |
|---|---|---|---|---|
| Units with a current dose check | 100% | Quarterly | Radiation protection lead | Escalate to the clinical 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 |
|---|---|---|
| DEN-REG-003 | Radiation equipment and dose audit register | Register |
17. Evidence
| Reference | Note |
|---|---|
| E-009 | Based on the CDC guidelines for infection control in dental health-care settings (Kohn et al., 2003), ISO 17665 for moist-heat sterilisation, the Minamata Convention on Mercury (2013), IAEA Specific Safety Guide SSG-46 (2018), Council Directive 2013/59/Euratom, and the ADA guidelines on sedation (2016). |
| 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)