Standards › Standard 57 › Policies
Policy · RTH-POL-001 · Version 1.0 · Approved by the ASF Expert Committee
Supports: 57.4
At a glance
- Treatment rooms have shielding and controlled areas that meet the design.
- Staff wear personal dosimeters, and the readings are reviewed at the set interval (RTH-REG-002).
- Pregnant staff and visitors are managed under this policy.
- Stop and get help straight away if: a staff member enters the treatment room without a dosimeter, or a dose reading above the set limit is not reviewed.
1. Purpose
To keep staff and visitors protected from radiation during treatment (57.4).
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
To keep staff and visitors protected from radiation during treatment (57.4).
5. Responsibilities
| Role | Responsibility | Competence |
|---|---|---|
| Radiation protection officer | Reviews the dosimetry readings and the shielding | Clinical lead |
| Radiographer | Keeps controlled areas clear and wears the dosimeter | Radiation protection officer |
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. Protect.
- Keep shielding in place and the controlled area clear during treatment.
Key point: Protected.
Step 2. Measure.
- Issue personal dosimeters and record the readings (RTH-REG-002).
Key point: Measured.
Step 3. Review.
- Review each reading at the set interval and act on any reading above the limit.
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 |
|---|---|---|---|---|
| Staff with readings reviewed at the interval | 100% | Quarterly | Radiation protection officer | Escalate to the hospital director |
| Readings above the limit with action recorded | 100% | Quarterly | Radiation protection officer | Review the shielding |
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 |
|---|---|---|
| RTH-REG-002 | Personal dosimetry register | Register |
| RAD-POL-001 | Radiation 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)