Radiography Records Documentation

---
name: radiography-records-documentation
description: |
  Create and maintain accurate, auditable records for work with patients attending for medical imaging.
  TRIGGERS - Use when a diagnostic radiographer needs a records & documentation for patients attending for medical imaging in an imaging department.
category: Radiography
license: MIT
version: 1.0
---
# Records & Documentation — Radiography

Create and maintain accurate, auditable records for work with patients attending for medical imaging. The deliverable is a documentation standard, templates and a completed record set.
This skill is written for a diagnostic radiographer working with patients attending for medical imaging in an imaging department.

## When to use
- You are a diagnostic radiographer preparing, delivering or reviewing this part of your work in an imaging department.
- You need a defensible, repeatable approach that produces a documentation standard, templates and a completed record set.
- A colleague, auditor or client asks how this was done and what evidence supports it.

## Key Concepts
| Term | Meaning |
|------|---------|
| Justification | confirming an examination's benefit outweighs its radiation risk |
| Reject analysis | reviewing why images were repeated |
| ALARP | radiation dose kept as low as reasonably practicable |

## Workflow
1. **Step 1** - Use examination requests as the single source of truth; record facts, observations and decisions — not speculation
2. **Step 2** - Write entries contemporaneously where possible, dated and attributable, in the format an imaging department requires
3. **Step 3** - Record measurements and outcomes that feed examination waiting times exactly as observed, with units and method noted
4. **Step 4** - Store and share records under the confidentiality and retention rules that apply in an imaging department, guarding against excess radiation dose
5. **Step 5** - Audit a sample of records monthly for completeness and correct anything missing while the work is still current

## Profession-Specific Components
| Component | Details for Radiography |
|-----------|-------------------------------|
| Core documentation | examination requests; dose records; image quality assessments; incident reports |
| Core tools & equipment | X-ray systems; CT and MRI scanners; image processing workstations; protective equipment |
| People involved | patients attending for medical imaging; the diagnostic radiographer; colleagues and other services in an imaging department |
| Primary record | examination requests — keep it current, dated and attributable |

## Output Format
**Context:** [Situation in an imaging department] | **Objective:** [What this must achieve] | **Audience:** [patients attending for medical imaging and other stakeholders]

The finished output is a documentation standard, templates and a completed record set, structured as:
1. Summary of position and evidence
2. Detail, following the workflow above
3. Decisions, actions, owners and dates
4. Review point and escalation route

### Action Plan
1. **Immediate:** Confirm scope, consent and the evidence available in examination requests.
2. **Short-term:** Complete the workflow steps and record outcomes against examination waiting times.
3. **Medium-term:** Review results, close actions, and update local procedures in an imaging department.

## Success Metrics
| Metric | Target | Method |
|--------|--------|--------|
| examination waiting times | Agree a local target and track the trend | Measured from examination requests and reviewed on a set cycle |
| image reject rate | Agree a local target and track the trend | Measured from examination requests and reviewed on a set cycle |
| dose compliance | Agree a local target and track the trend | Measured from examination requests and reviewed on a set cycle |
| report availability times | Agree a local target and track the trend | Measured from examination requests and reviewed on a set cycle |

## Guardrails & Quality Checks
- Never let this happen: excess radiation dose.
- Never let this happen: wrong patient imaged.
- Never let this happen: missed pregnancy checks.
- Work only within the competence and authority of a diagnostic radiographer; escalate or refer anything beyond it.
- Record facts and observations, not speculation, and keep records confidential to an imaging department's rules.
- Verify names, dates, figures and measurements twice before anything is issued or signed off.
- Use only real, verified information from the case in hand — never invent results, credentials or evidence.

## Example (illustrative)
A diagnostic radiographer in an imaging department applies this workflow for patients attending for medical imaging: they open
examination requests, work through the five steps using X-ray systems, and close by recording
the outcome against examination waiting times and agreeing the next review date. (Illustrative example only —
replace with the real details of the case in hand.)