The record · Having a scan
The paper trail
A scan produces an archive as well as an image. Most of that trail is compulsory under the 2017 regulations, and each document in it answers to a written duty.
What documents does a scan produce?
More than the image. A single examination under the UK framework generates a small archive: the written request that started it, the record of who carried it out, the evaluation of what it showed, and the report that travels back to the clinician who asked. The Ionising Radiation (Medical Exposure) Regulations 2017 make most of that trail compulsory rather than customary. Regulation 10(5) requires the referrer to supply "sufficient medical data" for the justification decision, and Schedule 2 requires written employer procedures covering identification of the individual, pregnancy and breastfeeding enquiries, prior information on benefits and risks, and the recorded evaluation of each exposure.
Keeping documents and objects legible over decades is a discipline with its own literature. The Sacred Object Journal, which documents the material culture of devotion, spends real attention on caring for old books and bindings: stable storage, condition notes, provenance. The scan's paper trail is the same idea in a clinical register, records kept so that what happened can be read back accurately long after the room has emptied.
What must the request contain?
Enough for someone else to judge it. Regulation 10(5) of IR(ME)R 2017 states that the referrer must supply the practitioner with "sufficient medical data (such as previous diagnostic information or medical records) relevant to the exposure requested" so that the practitioner can decide whether there is "a sufficient net benefit" under regulation 11. The request is therefore a piece of evidence, not a booking slip: it has to carry the clinical question and the material to weigh it.
The employer's written procedures shape the rest of the front end. Schedule 2 requires procedures "to identify correctly the individual to be exposed", to identify who is entitled to act as referrer, practitioner or operator and in what scope, and to make enquiries "of individuals of childbearing potential to establish whether the individual is or may be pregnant or breastfeeding". These are the entries at the head of the file, and they exist so that the exposure, if it proceeds, proceeds on the record.
Where is the evaluation recorded?
In the report, and in the department's own records. Schedule 2 requires a procedure "for the carrying out and recording of an evaluation for each exposure including, where appropriate, factors relevant to patient dose", and a separate procedure "for the assessment of patient dose and administered activity". The Royal College of Radiologists describes the professional who writes the evaluation: clinical radiologists are "specialist doctors trained to read and interpret medical images". Their report is the part of the trail that answers the referrer's question.
The trail has a failure branch too. Where a clinically significant unintended or accidental exposure occurs, Schedule 2 requires a procedure ensuring "that the referrer, the practitioner, and the individual exposed or their representative are informed of the occurrence... and of the outcome of the analysis". The Care Quality Commission's IR(ME)R annual report for 2020/21 shows the system working from the regulator's side: 85 notifications concerning patients referred for the wrong examination and 33 where the operator did not correctly identify the patient, with referrer errors "the highest origin of incidents reported".
| Document | What it records | Required by |
|---|---|---|
| The request | The clinical question and "sufficient medical data" to judge it | IR(ME)R 2017, regulation 10(5) |
| Identification and enquiry records | Who was exposed, and the checks made beforehand | IR(ME)R 2017, Schedule 2 |
| The evaluation | The recorded assessment of the exposure, including dose factors | IR(ME)R 2017, Schedule 2 para 1(j) |
| The report | The interpretation sent back to the requesting clinician | NHS examination pages; RCR role description |
| Incident notification | Any clinically significant unintended exposure and its analysis | IR(ME)R 2017, Schedule 2 para 1(l) |
Why the trail matters after the appointment
Because the answer to "what happened" must outlive everyone's memory of it. The recorded evaluation is what lets a later clinician see the basis of an earlier decision, and it is what the audit duty under regulation 7 reviews, "a systematic examination or review of medical radiological procedures" against agreed standards. The NHS result timings, "between 1 and 2 weeks" for CT and MRI, describe the speed of the last document in the trail reaching the person who asked for it. Where the images themselves are kept is covered in the page on where the pictures go.
Checked against the source
- The referrer must supply "sufficient medical data" for the justification decision (IR(ME)R 2017, regulation 10(5), legislation.gov.uk).
- Employer procedures must cover identification, entitled roles, pregnancy and breastfeeding enquiries, and prior information on benefits and risks (IR(ME)R 2017, Schedule 2).
- An evaluation must be carried out and recorded for each exposure (IR(ME)R 2017, Schedule 2 para 1(j)).
- Unintended or accidental exposures must be notified to the referrer, practitioner and individual (IR(ME)R 2017, Schedule 2 para 1(l); CQC annual report 2020/21).
- Clinical radiologists are "specialist doctors trained to read and interpret medical images" (Royal College of Radiologists, no displayed date).
Kept, but not for show
The record and the report are different documents. The report is the clinical answer sent back to the requester; the record is the wider file the employer must keep, covering identification, checks and dose factors under Schedule 2. One is written to be read; the other is kept so it can be audited.
The request and the referral letter are also worth separating. The request is the regulated act under regulation 10(5); the letter is its usual physical form. The regulation governs the content, the data sufficient for justification, not the paper it arrives on.