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Management of Diagnostic Radiography Orders – Adult/Pediatric – Inpatient/Ambulatory [139]

Management of Diagnostic Radiography Orders – Adult/Pediatric – Inpatient/Ambulatory [139] - Clinical Hub, UW Health Clinical Tool Search, UW Health Clinical Tool Search, Delegation/Practice Protocols, Ambulatory Delegation Protocols




Delegation Protocol Number: 139

Delegation Protocol Title:
Management of Diagnostic Radiography Orders – Adult/Pediatric – Inpatient/Ambulatory

Delegation Protocol Applies To:
All UW Health patients (Inpatient, Ambulatory, Urgent Care)

Target Patient Population:
All UW Health patients

Delegation Protocol Champions:
Michael Tuite, MD – Department of Radiology
Samuel Charles, MD – Department of Radiology
Kara Gill, MD – Department of Radiology

Delegation Protocol Reviewers:
Gina Greenwood, MBA – Director, Department of Radiology
Carol Hassemer, MHA – Director of Clinical Operations/Medical Imaging
Kari Pulfer, RT (R)(CT), MBA – Manager, Medical Imaging
Steve Tyska, MD – Department of Family Medicine – Urgent Care

Responsible Department:
Department of Radiology

Purpose Statement:
The purpose of this protocol is to delegate authority from the ordering provider to Registered Radiologic
Technologists (R.T.(R)s) to change electronic imaging order specifics that do not follow positioning
guidelines outlined in the UW Health Diagnostic Radiology Protocol Manual. This protocol does not
apply to advanced imaging modalities such as MRI or CT scans.

Who May Carry Out This Delegation Protocol:
Registered Radiologic Technologists (R.T.(R)s) trained in the use of this delegation protocol and who
have documented completion of training and passed competency
1. Each R.T.(R) completes training in correct positioning and routine views as part of the onboarding
process.
2. As part of the onboarding process, the R.T.(R)receives training regarding the UW Diagnostic
Radiology Protocol Manual.
3. Competency is assessed as part of the orientation/onboarding process and annual review
4. Quality assurance is assessed by the radiologist at the time of reading the radiographs.
4.1. There is an online QA process for feedback for the radiographs that allows for constructive
evaluation to the performing R.T.(R)
4.2. The QA feedback is reviewed by the manager or their delegate to assure follow up on
educational opportunities.


Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org



Guidelines for Implementation:
1. This protocol is initiated when a provider places an order for a diagnostic radiology exam that does
not follow positioning guidelines outlined in the UW Health Diagnostic Radiology Protocol Manual
2. R.T.(R) s will compare the provider order with the UW Health Diagnostic Radiology Protocol Manual.
3. Orders with conflicting imaging views will be modified by the R.T.(R) using Health Link change order
functionality which creates an audit trail back to the original provider order.
4. A study ordered for a patient by an ordering provider with specific view requests for specific
indications will be reviewed and approved by the division radiologist.

Order Mode: Cosign Required, Protocol/Policy

References: N/A

Collateral Documents/Tools:
UW Health Diagnostic Radiology Protocol
Manual https://uconnect.wisc.edu/clinical/references/radiographic/

Approved By:
UW Health Ambulatory Protocol Committee: March 2016
UW Health Radiology: March 2016
UW Health Center for Clinical Knowledge Management Council: March 2016
UWHC Medical Board: April 2016

Effective Date: April 2016

Scheduled for Review: April 2018
Copyright © 2017 University of Wisconsin Hospitals and Clinics Authority
Contact: Lee Vermeulen, CCKM@uwhealth.org Last Revised:
 
11/2017CCKM@uwhealth.org