Sample policy · Dental

IR(ME)R local rules (dental)

Statutory anchor: Ionising Radiation (Medical Exposure) Regulations 2017 (SI 2017/1322) is the primary law for this policy. It also engages Regulation 12 (safe care and treatment) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936), which is the CQC regulation quoted below. · primary source

1. What the regulation says

The Ionising Radiation (Medical Exposure) Regulations 2017 are the primary law for medical radiation exposures and are not held in the Verivius regulation manifest, so the verbatim quotes below are from the engaged CQC regulation, Regulation 12 (safe care and treatment). Read them alongside the IR(ME)R 2017 text at the primary source URL.

Care and treatment must be provided in a safe way for service users. (Reg 12(1) (the headline duty))

assessing the risks to the health and safety of service users of receiving the care or treatment, (Reg 12(2)(a) (risk assessment))

doing all that is reasonably practicable to mitigate any such risks, (Reg 12(2)(b) (risk mitigation))

ensuring that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely, (Reg 12(2)(c) (staff competence))

ensuring that the equipment used by the service provider for providing care or treatment to a service user is safe for such use and is used in a safe way, (Reg 12(2)(e) (equipment safety))

The full text of the engaged CQC regulation is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12 and the full text of IR(ME)R 2017 is at https://www.legislation.gov.uk/uksi/2017/1322/contents. Where this policy and the regulation diverge, the regulation wins.

2. Plain-English summary

Care and treatment must be provided in a safe way. The regulation lists the areas a provider must address, including risk assessment, risk mitigation, staff competence, safe premises, safe equipment, sufficient equipment and medicines, medicines safety, infection prevention and shared-care planning. Regulation 12 is central to CQC's safety expectations. For dental radiography, the IR(ME)R 2017 framework sets the detailed duties on top of this safe-care baseline.

3. Purpose and scope

These local rules set out how the Practice manages dental radiography under the Ionising Radiation (Medical Exposure) Regulations 2017 and related guidance.

The Practice must verify these rules against the current IR(ME)R 2017 legislation, the 2024 amendment guidance and its appointed radiation protection advisers before adoption.

They apply to every dental radiographic exposure carried out by or on behalf of the Practice, every location and item of imaging equipment, all referrers, practitioners and operators entitled under the employer's procedures, and staff who maintain records, equipment or the quality assurance system.

Before adoption, the Practice must record the legal employer, entitled duty holders, equipment and locations, adviser contacts, local diagnostic reference arrangements, notification decision route and the exact employer's procedures in force.

4. Sources to verify before adoption

5. Equipment inventory

The Practice keeps a current inventory of radiography equipment. The inventory includes:

For each item, the inventory records:

6. Duty holders

The Practice records named people or role holders for each IR(ME)R duty holder.

The same person may hold more than one role only where the current IR(ME)R source and employer's procedures allow it.

Operational roles and responsibilities

7. Justification process

No dental radiographic exposure is made until it has been justified and authorised according to the employer's procedures.

Before justification, the practitioner considers:

The Practice does not use standing wording from this template as a substitute for the current IR(ME)R justification requirements. The employer's procedure must cite the current source.

Step-by-step exposure procedure

  1. Receive a valid referral. Confirm the referrer is entitled and the referral identifies the patient, clinical question and examination requested.
  2. Identify the patient and check relevant information. Use the local identifier standard, review previous imaging where available and apply pregnancy-enquiry procedures where relevant.
  3. Justify and authorise. An entitled practitioner weighs the expected benefit and radiation risk and records the decision before exposure.
  4. Select and optimise the exposure. An entitled operator chooses the approved protocol and patient-specific settings, then checks positioning and equipment readiness.
  5. Carry out and record the exposure. Record the operator, equipment, exposure details, image quality and any deviation or repeat.
  6. Evaluate and report. Make sure the image receives the required clinical evaluation and the outcome reaches the patient record and responsible clinician.
  7. Escalate an exception. Stop and follow the accidental or unintended exposure process for a wrong patient, wrong examination, equipment fault, significant dose concern or other suspected failure.

8. Optimisation

The Practice keeps exposures as low as reasonably practicable while still achieving an image that answers the clinical question.

The local optimisation procedure covers:

The Practice reviews repeat images as part of clinical audit.

9. Dose recording and image records

The Practice records radiographic exposure information in the patient record or linked radiography record according to the local procedure.

Records include:

Radiographs, consent forms and related recordings form part of the patient record under GDC record-keeping standards. The Practice verifies the detail against GDC Principle 4 before adoption.

10. Accidental or unintended exposure

The Practice has a written process for suspected accidental or unintended exposure.

The process includes:

Staff do not decide notification thresholds from memory. The Practice checks the current CQC IR(ME)R notification criteria and current IR(ME)R guidance before making a notification decision.

11. Quality assurance, audit and monitoring cadence

The Practice keeps a radiography quality assurance schedule for each equipment type.

The schedule covers:

The Practice must set the exact frequency and check type from the current IR(ME)R guidance, equipment manufacturer's instructions and adviser recommendations. This template does not restate regulatory test intervals.

12. Training requirements

Staff only act as referrer, practitioner or operator where the employer's procedures entitle them to do so and their training record supports the role.

The training record includes:

The Practice checks current GDC and IR(ME)R expectations before approving role entitlement.

13. Review and document control

The Registered Manager reviews these local rules:

Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.

14. Related policies in this pack

15. Sources and further reading

This template is based on CQC's guidance for providers and managers, the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, and other topic-specific legislation and guidance listed below. It is a starting point for adaptation, not a substitute for legal, clinical, HR, safeguarding or specialist professional advice.

16. When to seek further advice

Seek specialist advice where the issue involves serious harm, safeguarding, deprivation of liberty, restraint, children, professional misconduct, controlled drugs, radiation, termination of pregnancy, infection outbreak, water safety, employment dismissal, DBS barring referral, or regulatory enforcement.

17. Document control

Version Date Author Changes
v1.1 2026-07-18 Verivius (sample) Added scope, operational ownership, the exposure procedure, explicit audit cadence and related policies.
v1 2026-06-10 Verivius (sample) Initial sample template, conformed to the Verivius policy standard.

This sample policy template was issued by Verivius. It is a template, not a substitute for legal advice or the provider's own policy-development process. Where this template and live law or regulator guidance diverge, the live source wins.

What good looks like here

Written from an ex-CQC inspector's chair, but the point is safe, well-led care your team can stand behind. Each row shows what strong evidence looks like, what thin evidence looks like, and where the expectation comes from.

The harm this policy guards against is invisible: a person cannot see or feel a dose of ionising radiation, so an unjustified dental radiograph, a routine full-mouth set taken because it is the practice habit, or a repeat taken carelessly all deliver a real risk that bought the patient nothing, and the people most exposed to that trade are children and anyone imaged often. This is why an inspector reads the justification trail before anything else: not the dose figure itself, which lives in the equipment and the adviser's diagnostic reference levels, but whether an entitled practitioner asked a genuine clinical question of this person before the button was pressed, whether the person taking the exposure was entitled and trained to take it, and whether an accidental or unintended exposure would be caught, notified against the current criteria and learned from rather than quietly repeated. The value of that recorded trail is that each exposure can be shown to have earned its dose, and that the practice would notice an over-exposure rather than carry on.

  1. Every dental X-ray is taken only after an entitled practitioner has justified it against a real clinical question for this particular person and authorised it before exposure, so the record shows why this image was needed now, not simply that a radiograph was taken.

    Strong evidence: The per-exposure justification and authorisation entry in the patient record: the clinical question, confirmation that previous imaging and any non-radiographic option were considered, who justified and authorised the exposure, and that the decision was made before the exposure rather than written up afterwards.

    Weak evidence: A run of new-patient radiographs whose reason field is identical or blank, justification signed after the image was already taken, or a repeat exposure with no reason logged. Also weak: a justification recorded against the name of someone who is not on the practice's entitlement list.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Ionising Radiation (Medical Exposure) Regulations 2017, reg 11 (justification of individual exposures), read with reg 10 (duties of the practitioner, operator and referrer)

  2. Only people the employer's procedures actually entitle carry out each function, and each works within the scope their training supports, so an intra-oral-only operator does not take a cone-beam CT exposure and nobody justifies an exposure they were never entitled to justify.

    Strong evidence: The employer's procedures naming the entitled referrers, practitioners and operators, cross-referenced to each person's training and competency file, with scope limits (for example intra-oral only, or cone-beam CT excluded), IR(ME)R and equipment-specific training, and dated competency sign-off.

    Weak evidence: An entitlement list that predates two of the current clinicians, a locum operating with no recorded entitlement, or cone-beam CT exposures taken by someone whose file holds no cone-beam CT training. A blanket 'all dentists entitled' line with no per-person scope or refresher date.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Ionising Radiation (Medical Exposure) Regulations 2017, reg 6(1)(a) (the employer's written procedures) with Schedule 2(b) (the procedure identifying the individuals entitled to act as referrer, practitioner or operator within a specified scope of practice), and reg 17 (training), read with reg 10 (duties of the practitioner, operator and referrer)

  3. A suspected accidental or unintended exposure, whether a wrong patient, a wrong site, an unintended repeat or an equipment fault, triggers immediate clinical review, an entry in the incident register and advice from the medical physics expert or radiation protection adviser, and the notification threshold is checked against the current CQC IR(ME)R criteria each time rather than judged from memory.

    Strong evidence: The accidental or unintended exposure record: the clinical review, the medical physics expert or radiation protection adviser advice recorded as advice plus the decision taken, the assessment against the current CQC IR(ME)R notification criteria with its reasoning, and the corrective action tracked to completion.

    Weak evidence: An over-exposure written up in the incident log with the notification decision left blank, a notification made or ruled out with no reference to the current criteria, or adviser input recorded as 'discussed by phone' with no note of the decision reached. The duty of candour conversation owed to the person is missing, or is treated as discharged by making the notification.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Ionising Radiation (Medical Exposure) Regulations 2017, reg 8 (employer's duties: accidental or unintended exposure); the duty of candour under Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, reg 20 is a separate duty owed to the person and neither discharges nor is discharged by an IR(ME)R notification to CQC

  4. The written employer's procedures in force are current, cite the live IR(ME)R source rather than standing template wording, and match the equipment and roles the practice actually has, so the procedure staff follow is the one that reflects the cone-beam CT unit installed last year, not a version superseded when the kit or the people changed.

    Strong evidence: The dated employer's procedures with a review history, covering patient identification and pregnancy enquiry, justification, optimisation, clinical evaluation, local diagnostic reference arrangements and the accidental-exposure route, referenced to the current equipment inventory and to named adviser contacts (radiation protection adviser and medical physics expert), and reviewed after any equipment or role-holder change.

    Weak evidence: Procedures still carrying template placeholder wording, no named legal employer or entitled duty holders recorded, local diagnostic reference arrangements left blank, or a procedure set last reviewed before the current equipment was installed.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Ionising Radiation (Medical Exposure) Regulations 2017, reg 6(1)(a), with the employer's procedures set out in Schedule 2

  5. Each exposure is optimised so the image answers the clinical question at a dose kept as low as reasonably practicable, and enough is recorded about it, including the dose information the unit provides and an image-quality grade, that optimisation can be shown from the records rather than only asserted, with repeats reviewed and reduced through audit rather than left to accumulate.

    Strong evidence: The exposure records holding the reason, equipment, operator, the dose information where the equipment provides it and the image-quality grading, together with the reject and repeat analysis and the review of exposures against the practice's local diagnostic reference levels.

    Weak evidence: Image-quality grading absent, a reject and repeat rate that has never been calculated, or dose information the equipment displays never captured in the record. Local diagnostic reference levels never set, so there is nothing an exposure can be compared against.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Ionising Radiation (Medical Exposure) Regulations 2017, reg 12 (optimisation), read with reg 6(5)(c) (the duty to establish and regularly review diagnostic reference levels)

  6. The radiography quality assurance and clinical audit programme runs at the frequency the practice's adviser and current guidance set, and its findings produce actions that close, so an image-quality drift or a rising repeat rate is caught and corrected rather than a downloaded checklist being scored highly and filed.

    Strong evidence: The quality assurance schedule per equipment type with completed routine checks, the reject and repeat clinical audit, equipment performance, service and maintenance records in date, and the actions arising tracked to completion with re-audit where needed.

    Weak evidence: A quality assurance schedule with cells left blank for months, equipment performance checks lapsed with no next-due date, or an audit completed with no action, no re-audit and nothing to show practice changed. The duty to run a quality assurance programme and clinical audit is statutory under IR(ME)R 2017 (reg 6(5)(b) (quality assurance programmes) and reg 7 (clinical audit)); the test intervals and standards come from the adviser and current guidance, not from a fixed figure in this template.

    A legal duty. This comes from legislation that applies to your service, so meeting it is not optional. The exact provision is cited beneath the badge.

    Ionising Radiation (Medical Exposure) Regulations 2017, reg 6(5)(b) and reg 7. The existence of a quality-assurance programme and of clinical audit with action on findings is the statutory duty; the test methods, standards and frequencies come from professional guidance and the medical physics expert.

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Last verified 20 July 2026

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Last reviewed 10 June 2026