UW HEALTH CLINICAL POLICY 1
Policy Title: Recording and Review of X-Ray Exposure for Procedures Using
Policy Number: 3.5.6
Category: UW Health
Type: Ambulatory and Inpatient
Effective Date: July 13, 2017
The purpose of this policy is to establish requirements for recording patient exposure for fluoroscopic exams
performed at UW Health facilities which would enable the institution to:
A. Evaluate radiation doses administered to fluoroscopy patients in different types of procedures and ensure
that doses are consistently appropriate for the imaging requirements.
B. Make a reasonable estimate of the dose received by patients, in the event that a concern regarding radiation
C. Identify any patients for whom the threshold for x-ray induced skin injuries has been approached or
exceeded, so that additional details of the exposure can be included in the patient chart as recommended by
the FDA, and so that appropriate follow-up, monitoring and care may be administered.
II. POLICY ELEMENTS
A. Available radiation dose information and other study information listed in Section III B shall be recorded for
all procedures performed using x-ray fluoroscopy at UW Health facilities, where the fluoroscope is capable
of being operated at an x-ray tube potential of at least 90 kVp and an x-ray tube current of at least 1
mA. Fluoroscopic devices not capable of being operated at an x-ray tube potential of at least 90kVP and an
x-ray tube current of at least 1mA (e.g., Mini C-arms) are exempt as the x-ray dose to the patient resulting
from procedures on these units is insignificant.
B. Dose information shall be monitored throughout the procedure. Communication regarding dose levels and
total fluoroscopic exposure time will take place with the responsible physician as appropriate. This
information will also be reviewed and recorded at the end of the procedure. Any procedure using more x-ray
dose than an established threshold level for the fluoroscope shall also be documented in the patient chart
with sufficient detail to show areas of potential x-ray induced skin injuries to aid in follow-up, monitoring and
care of x-ray induced injuries. The threshold dose is 5000 mGy cumulative air kerma at the interventional
reference point. If cumulative air kerma is not available on the fluoroscope, an appropriate surrogate dose
value and threshold will be established in consultation with Medical Physics.
C. When the 5000 mGy threshold level is reached, the technologist, x-ray unit operator, or other person
designated by the section manager is responsible for documenting study information in the patient's chart
via Form #4007833 “Record of X-ray Exposures Approaching the Skin Erythema Dose”, with other
documentation of the procedure performed. The person documenting the study is also responsible for
providing the information to the physician or the physician’s designee (e.g., nurse coordinator, nurse
practitioner, radiologist) to initiate follow-up with the patient.
D. When the 5000 mGy threshold level is reached, information on the potential for x-ray produced skin effects
shall be provided to the patient (Health Facts For You #6089: "Skin Reactions from X-ray Exposure and
HFFY #7168 Skin Care for Radiation Exposure in the Heart and Vascular Laboratory).
E. If the total air kerma at the interventional reference point exceeds 10,000 mGy, or if follow-up observations
show a significant skin reaction, the Medical Physicist shall be alerted promptly and requested to perform an
analysis to determine peak skin dose. If the peak skin dose is determined to potentially cause a serious skin
reaction requiring medical treatment, a Patient Safety Net report will be submitted. In addition, if the peak
skin dose is determined to be greater than or equal to 15,000 mGy, notification shall be given to Risk
Management per UW Health clinical policy #1.3.2, Reporting Unexpected Events and Determination of
Sentinel Event Status.
A. For each fluoroscopic exam performed on an x-ray fluoroscope capable of operating at an x-ray tube
potential of at least 90 kVp and an x-ray tube current of at least 1 mA, the study information (in III.B.) will be
entered into Health Link.
B. The following information will be recorded for each fluoroscopic exam:
i. Cumulative Air Kerma (if available)
UW HEALTH CLINICAL POLICY 2
Policy Title: Recording and Review of X-Ray Exposure for Procedures Using Fluoroscopy
Policy Number: 3.5.6
ii. Exam Date
iii. Patient Medical Record Number
iv. Exam Type
v. Technologist Name or Number
vi. Total Fluoroscopy Time
vii. Dose Area Product (if available)
C. The department Medical Physicist will review each case where the threshold level is exceeded to ensure
that the dose delivered to the patient was necessary for the intended purpose of the procedure and, if
appropriate, to make any recommendations that could reduce the dose for similar procedures in the future.
These recommendations will be reviewed by the Radiation Safety Committee.
D. The UW Health fluoroscopic units will be operated as directed by and in compliance with UW Health
administrative policy #7.10, Utilization of Radiological Equipment.
Form #4007833, Record of X-ray Exposures Approaching the Skin Erythema Dose
HFFY #6089, Skin Reactions from X-ray Exposure
HFFY #7168 Skin Care for Radiation Exposure in the Heart and Vascular Laboratory
Author: Director of Safety
Senior Management Sponsor: VP, Professional Services
Reviewers: UWSMPH Department of Medical Physics
Approval committees: Radiology Quality, Safety, and Innovation Committee; UW Health Clinical Policy
UW Health Clinical Policy Committee Approval: June 19, 2017
UW Health is a cohesive, united and integrated academic medical enterprise comprised of several entities.
This policy applies to facilities and programs operated by the University of Wisconsin Hospitals and Clinics
and the University of Wisconsin Medical Foundation, Inc., and to clinical facilities and programs
administered by the University of Wisconsin School of Medicine and Public Health. Each entity is
responsible for enforcement of this policy in relation to the facilities and programs that it operates.
Peter Newcomer, MD
Chief Clinical Officer
J.Scott McMurray, MD
Chair, UW Health Clinical Policy Committee
UW Health administrative policy #7.10, Utilization of Radiological Equipment
UW Health clinical policy #1.3.2, Reporting Unexpected Events and Determination of Sentinel Event Status
VIII. REVIEW DETAILS
Last Full Review: July 13, 2017
Next Revision Due: July 2020
Formerly Known as: Hospital Administrative policy #8.98