INTERNAL AUDIT REPORT (RADIOLOGY)
Area/Department: RADIOLOGY Month :
Auditee:
S. No. Audit Points Observation
1 List of Manuals & Records available in the department
2 Legal requirements of imaging services
BARC Clearance
Dosimeters
Lead Sheets
Signage
Display PNDT Act
Reports to Statutory Authority
Appointment of RSO
3 Scope of Imaging services is as per services of the organization.
4 Infrastructure- Physical facility and manpower is adequate for its
services.
List of Equipment
List of Manpower
No delay reporting is done due to lack of
manpower/Equipment.
5 Qualified and Trained personnel
Adequately qualified and trained personnel perform,
supervise and interpret the investigation.
Staff list with qualification, training as per AERB
Guidelines.
6 Policies and Procedures for identification and safe transportation of
patient to imaging services followed
7 TAT of imaging result within defined time frame monitored and
documented
8 Critical test register /results intimated immediately.
Critical results are defined and displayed.
Critical results are intimated to treating clinician at
the earliest on phone, followed by written report.
Documentation of critical result intimation is to be
done
9 Result reported in a standardized format.
Name of the hospital
Patient name
Unique identification number
Name and signature of the reporting person.
10 Outsourced imaging tests is done based on quality assurance
system.
List of tests for outsourcing
Identity of personnel in outsourced facility to
ensure.
Safe transportation of patient
Completion of imaging results.
Manner of Identification of patients. Test requisition
with all details.
Checklist to check the selection and performance of
services as per requirement of the organization.
MOU/Agreement including QA and requirement of
the standard.
11 Quality Assurance Programme
a. AERB – Q.A. Report verifying the safety points of radiation
i.e.
Congruence of optical and radiation field
Focal spot size
Output Consistency
Leakage rate
Verification and Validation methods.
13 b. Surveillance of imaging results
HOD to periodically asses the imaging results.
Fix frequency and sample size.
c. Periodic calibration and maintenance of all equipment’s,
traceability certificates of all calibration done by calibrated
equipment’s to be documented.
14 d. The programme includes the documentation of corrective
and preventive actions.
15 RADIATION SAFETY PROGRAM
a. Radiation safety programme is documented (AERB
Guidelines)
17 b. Handling usage and disposal of radioactive and hazardous
materials are dealt with as per statutory requirements.
Availability of MSDS display
Training of staff on MSDS(Record)
18 c. Radiation safety devices
Lead Apron
Shields
Dosimeters etc
19 d. Radiation safety devices periodically documents
Lead apron, x-ray to detect cracks once in a year
X-Ray film stored for reference
Appropriate CAPA to be taken.
20 e. Training on Radiation safety measures.
21 f. Imaging signage’s are prominently displayed.
Safety signals
Display of signage as required by regulatory body.
Informed consent has been taken for CT
22 HIC
Hand hygiene, PPE, BMW, Sterilization process, cleaning record of
AC & AC ducts.
24 Crash Cart Inventory, High Risk Medication, Temp. control
maintained
25 Fire Training, BLS Training, CPR Training done
26 PRE
Patient rights and education
Patient safety checklist filled
27 Red Lights working
28 Quality indicators monitored and documented
All adverse events are monitored and intimated within
stipulated time
Name/ Sign of Auditor:
Name/ Sign of Auditor:
