Sample policy · Diagnostic imaging

Image reporting standards and turnaround policy (diagnostic imaging)

Statutory anchor: Regulation 12 (safe care and treatment), Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 (SI 2014/2936). This policy also engages Regulation 17 (good governance). The primary professional standards for imaging reporting are the RCR Standards for the interpretation and reporting of imaging investigations, RCR recommendations on alerts and notification of imaging reports, NHS England reporting turnaround standards, and, for radiation-bearing examinations, the Ionising Radiation (Medical Exposure) Regulations 2017 (IR(ME)R 2017). · primary source

1. Who this diagnostic imaging reporting policy is for

This sample policy is for diagnostic imaging providers that need a reporting standards and turnaround policy. It is written for independent ultrasound, MRI, CT, X-ray, mammography, fluoroscopy and mixed-modality services that acquire images and issue, arrange or rely on clinical reports.

Use this page when the evidence question is: can we show that reports are issued by competent reporters, within defined turnaround standards, with urgent findings escalated, report issue recorded, discrepancies reviewed and delays turned into learning? It focuses on reporter scope, report content, turnaround targets, urgent findings, peer review, discrepancy learning and the audit trail from acquisition to report receipt.

For clinically important unexpected findings, use the incidental findings disclosure and follow-up policy. For radiation-bearing examinations, use the IR(ME)R local rules and radiation safety policy. For MRI access and screening risk, use the MRI safety and screening policy. For contrast reactions, use the contrast media safety policy. For the wider sector cluster, see the diagnostic imaging guide.

2. What the regulation says

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))

where responsibility for the care and treatment of service users is shared with, or transferred to, other persons, working with such other persons, service users and other appropriate persons to ensure that timely care planning takes place to ensure the health, safety and welfare of the service users. (Reg 12(2)(i) (shared / transferred responsibility))

Regulation 17 adds the good-governance duties that this policy operationalises:

Systems or processes must be established and operated effectively to ensure compliance with the requirements in this Part. (Reg 17(1): the umbrella duty)

assess, monitor and improve the quality and safety of the services provided in the carrying on of the regulated activity (including the quality of the experience of service users in receiving those services) ... assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activity. (Reg 17(2)(a) and (b): quality and risk)

The full text is at https://www.legislation.gov.uk/uksi/2014/2936/regulation/12 and https://www.legislation.gov.uk/uksi/2014/2936/regulation/17. Where this policy and the regulation diverge, the regulation wins.

3. 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. Reporting standards, reporter scope, urgent-finding communication and turnaround monitoring are how an imaging service shows that the report part of the pathway is competent, timely and safe, and that risks created by delay, discrepancy or out-of-scope reporting are assessed and mitigated.

4. Purpose

This policy sets out how the Service maintains reporting standards, reporter scope, turnaround monitoring, urgent finding communication, peer review and discrepancy learning.

It covers the audit trail from image acquisition to report issue and referrer receipt.

5. Modality applicability

Modality applicability: this policy applies to ultrasound, MRI, CT, X-ray, mammography, fluoroscopy and other imaging examinations where the Service acquires images and issues, arranges or receives a clinical report.

6. Scope

This policy applies to:

The policy applies to direct reporting by the Service and outsourced reporting arranged under the Service's governance.

7. Reporting workflow

The Service keeps a complete audit trail from scan acquisition to report receipt by the referrer or responsible clinician.

7.1 Acquisition and report request

Staff record the examination before images are released for reporting.

The record includes:

Staff escalate immediately if an image cannot be transferred, stored or retrieved.

7.2 Reporter qualification and scope

The Service keeps a reporter scope matrix.

The matrix records:

Sonographers and reporting radiographers report only within documented scope. The Radiologist reviews scope exceptions and records the decision.

7.3 Report content standard

The report answers the clinical question where possible and records limitations.

The report includes:

The Service checks the detailed report standard against current RCR, SCoR and modality guidance before adoption.

7.4 Report issue and receipt

The Service records that the verified report has been issued to the referrer or responsible clinician.

The record includes:

Reports are not treated as complete until issue has been recorded.

8. Turnaround standards and escalation

The Service sets reporting turnaround targets by modality, urgency and contract type.

Targets must be verified against current NHS England, RCR, commissioner and local source material before adoption. Where no external target applies, the Service labels the target as a local Verivius default.

The turnaround record includes:

Delayed reporting is recorded as an incident where delay creates patient risk, complaint risk or repeated governance concern.

9. Urgent findings, peer review and discrepancy learning

9.1 Urgent findings

The Service has a written urgent-findings communication pathway.

The pathway records:

The reporter does not rely on a report alone where the local urgent-findings standard requires direct alerting.

9.2 Peer review

The Service runs peer review according to local modality and professional requirements.

Peer review covers:

Peer review is recorded as learning, not blame, unless conduct or competence concerns require separate action.

9.3 Discrepancy and report quality issue

The Service records a discrepancy or report quality issue when a report is materially wrong, unclear, delayed or outside reporter scope.

The review checks:

10. Responsibilities

11. Recording requirements

The Service keeps the following records:

Records are kept in the Service governance records and linked to the patient record where relevant.

12. Audit cadence

The Service uses the following Verivius default audit rhythm unless current RCR, SCoR, NHS England, CQC, commissioner or local source material requires a different rhythm:

Audit findings are recorded as improvement actions with an owner and review date.

13. Version control and review date

The Service keeps a controlled copy of this policy. The footer or document-control table records:

14. Related records

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

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 2026-06-10 Verivius (sample) Conformed to the Verivius policy standard: added statutory anchor, verbatim Regulation 12 and Regulation 17 quotes, plain-English summary, sources and further reading, when-to-seek-advice and document-control blocks. All original sections retained and renumbered from 3.
v1.1 2026-07-11 Verivius (sample) Added diagnostic-imaging reporting-turnaround intent guidance and links to related imaging policy pages and the sector guide. No regulatory claims changed.

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

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Last reviewed 10 June 2026