1. 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.
2. Sources to verify before adoption
- RCR standards for interpretation and reporting of imaging investigations: https://www.rcr.ac.uk/our-services/all-our-publications/clinical-radiology-publications/standards-for-interpretation-and-reporting-of-imaging-investigations-third-edition/
- RCR recommendations on alerts and notification of imaging reports: https://www.rcr.ac.uk/our-services/all-our-publications/clinical-radiology-publications/recommendations-on-alerts-and-notification-of-imaging-reports/
- NHS England diagnostic imaging reporting turnaround times: https://www.england.nhs.uk/long-read/diagnostic-imaging-reporting-turnaround-times/
- Society of Radiographers professional guidance and publications: https://www.sor.org/
- SoR and BMUS Guidelines for Professional Ultrasound Practice: https://www.bmus.org/media/resources/files/_2023_SoR_and_BMUS_guidelines_8th_Ed_FINAL.pdf
- HCPC standards of proficiency for radiographers: https://www.hcpc-uk.org/standards/standards-of-proficiency/radiographers/
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 12: https://www.legislation.gov.uk/uksi/2014/2936/regulation/12
- Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Regulation 17: https://www.legislation.gov.uk/uksi/2014/2936/regulation/17
3. Scope
This policy applies to:
- image acquisition and report creation
- reporter qualification and scope
- radiologist reporting
- sonographer and reporting radiographer scope where used
- urgent and unexpected findings
- turnaround targets
- report issue and receipt
- outsourcing or insourcing reporting
- peer review and discrepancy meetings
- delayed reporting and report quality incidents
The policy applies to direct reporting by the Service and outsourced reporting arranged under the Service's governance.
4. Reporting workflow
The Service keeps a complete audit trail from scan acquisition to report receipt by the referrer or responsible clinician.
4.1 Acquisition and report request
Staff record the examination before images are released for reporting.
The record includes:
- patient identity
- examination type
- modality
- indication or clinical question
- referrer or responsible clinician
- date and time of acquisition
- operator
- reporter assigned
- urgency category
- images transferred for reporting
- technical limitations or incomplete examination
Staff escalate immediately if an image cannot be transferred, stored or retrieved.
4.2 Reporter qualification and scope
The Service keeps a reporter scope matrix.
The matrix records:
- reporter name and role
- professional registration
- modality scope
- body-system or examination scope
- independent reporting status
- supervision or second-read requirement
- date of competency sign-off
- peer review participation
- restrictions and exclusions
Sonographers and reporting radiographers report only within documented scope. The Radiologist reviews scope exceptions and records the decision.
4.3 Report content standard
The report answers the clinical question where possible and records limitations.
The report includes:
- patient identity
- examination performed
- date of examination
- clinical indication
- relevant findings
- conclusion or impression
- urgent or unexpected finding flag where applicable
- recommended follow-up where within scope
- reporter name and role
- date and time of verification
The Service checks the detailed report standard against current RCR, SCoR and modality guidance before adoption.
4.4 Report issue and receipt
The Service records that the verified report has been issued to the referrer or responsible clinician.
The record includes:
- report verification date and time
- transmission route
- recipient
- failed transmission or bounce-back
- manual resend where needed
- urgent communication route where applicable
- confirmation of receipt where local policy requires it
Reports are not treated as complete until issue has been recorded.
5. 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:
- acquisition time
- report assigned time
- report verified time
- report issued time
- referrer receipt confirmation where required
- reason for delay
- escalation action
Delayed reporting is recorded as an incident where delay creates patient risk, complaint risk or repeated governance concern.
6. Urgent findings, peer review and discrepancy learning
6.1 Urgent findings
The Service has a written urgent-findings communication pathway.
The pathway records:
- finding category
- responsible reporter
- clinician contacted
- contact route
- date and time
- advice or action requested
- failed contact attempts
- follow-up confirmation
The reporter does not rely on a report alone where the local urgent-findings standard requires direct alerting.
6.2 Peer review
The Service runs peer review according to local modality and professional requirements.
Peer review covers:
- sample selection
- modality mix
- reporter mix
- discrepancy category
- learning point
- individual support where needed
- system improvement where needed
Peer review is recorded as learning, not blame, unless conduct or competence concerns require separate action.
6.3 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:
- clinical impact
- whether an amended report is needed
- whether the referrer and patient need communication
- whether duty of candour applies
- whether reporter scope or supervision needs review
- whether the issue indicates a wider pathway problem
7. Responsibilities
- Registered Manager: owns this policy, ensures reporting governance is reviewed and signs off annual review.
- Radiologist: owns reporting standards, urgent finding escalation, peer review and discrepancy governance.
- Lead Sonographer: assures ultrasound reporting scope and escalates findings outside scope.
- Reporting radiographer or sonographer: reports only within documented scope and records urgent communication where required.
- Radiographer or operator: records acquisition details, image-quality limitations and image transfer exceptions.
- Administration staff: monitor report issue, failed transmission and turnaround exceptions where delegated.
- All staff: escalate reporting delays or urgent communication failures promptly.
8. Recording requirements
The Service keeps the following records:
- examination record
- report request
- reporter scope matrix
- report
- urgent finding communication record
- report issue record
- turnaround monitoring record
- failed transmission record
- peer review record
- discrepancy record
- delayed reporting incident
- duty of candour decision
- improvement action record
Records are kept in the Service governance records and linked to the patient record where relevant.
9. 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:
- Per examination: Staff record acquisition, report verification and report issue details.
- Weekly: the reporting lead reviews overdue reports and failed transmission records.
- Monthly: the Radiologist reviews turnaround performance, urgent findings and report quality incidents.
- Quarterly: the Service reviews peer review outputs, discrepancies and reporter scope exceptions.
- Annually: the Registered Manager audits this policy against current source material and updates targets.
Audit findings are recorded as improvement actions with an owner and review date.
10. Version control and review date
The Service keeps a controlled copy of this policy. The footer or document-control table records:
- policy owner
- version number
- date approved
- next review date
- changes made since the last version
- source material checked during the review
11. Related records
- Reporter scope matrix
- Examination record
- Imaging report
- Urgent findings communication log
- Turnaround dashboard
- Peer review record
- Discrepancy register
- Incident register
- Duty of candour policy
- Improvement action register
Review cadence: annual or on regulatory change, whichever sooner. Owner: Registered Manager.