Health Care Department Operations Manual

Chapter 3 – Health Care Operations

Article 1 – Complete Care Model

3.1.13 Medical Imaging Services

Policy
- California Correctional Health Care Services (CCHCS) staff shall ensure patients have timely access to safe and cost-effective medical imaging services that are medically necessary to establish diagnoses, make recommendations for additional diagnostic work-up, and establish treatment plans. The Medical Imaging Services (MIS) program shall perform, process and interpret results of medical imaging examinations both within the institutional MIS departments and through contracted onsite services. The MIS program shall maintain accurate records of both onsite and offsite medical imaging in a retrievable manner for a minimum of seven years, adhering to all applicable retention, privacy and security, and safety guidelines as required by federal and state laws.
Responsibility
- Statewide
  - California Department of Corrections and Rehabilitation and CCHCS departmental leadership at all levels of the organization, within the scope of their authority, shall ensure administrative, custodial, and clinical systems are in place and appropriate tools, training, technical assistance, and resources are available to ensure patients have timely access to safe and cost-effective medical imaging services that are medically necessary.
  - The Statewide Chief, MIS is responsible for the implementation and maintenance of a safe and effective MIS program to include:
    - Develop statewide standard operating procedures for use at the local level.
    - Monitor annual institution Radiology Supervisor & Operator (RS&O) and quarterly mammography inspections, medical imaging equipment registration and calibration, and radiation safety procedures.
    - Provide oversight and initiating statewide MIS contracts, procurements, policies and procedures, workflows, and forms. Monitor the execution of statewide contracts and procurement agreements.
    - Provide oversight of all medical imaging examination preparations and protocols and quality assurance of all examinations performed onsite, in conjunction with the CCHCS contracted radiology group.
    - Provide consultation and advice to health care providers and institution staff regarding their institution MIS departments.
- Regional
  - Regional Health Care Executives are responsible for implementation of this procedure at the subset of institutions within an assigned region.
  - The Regional Health Care Executive is responsible for the oversight of the assigned regional Senior Radiologic Technologist (SRT) staff.
    - The Statewide MIS Chief shall provide functional direction to the SRT staff.
  - The SRT shall:
    - Perform administrative duties at the regional level.
    - Monitor and assist MIS operations at multiple institutions within their assigned region.
    - Perform institution-based medical imaging duties as needed and when appropriate.
    - Monitor institution-based MIS staff performance within their assigned region through regular onsite compliance auditing, training, competency verification, and any subsequent remediation.
    - Coordinate with the Statewide MIS Chief, or designee, and the appropriate hiring authority, or their designee, on all competency verification related processes, findings, and remediation.
- Institutional
  - The Chief Executive Officer (CEO), or designee, is responsible for implementation of this policy at the institution level.
  - The Chief Support Executive (CSE) or Correctional Health Services Administrator (CHSA) shall:
    - Hire institution MIS staff members, ensuring appropriate training is provided and completed, and monitoring of staff performance. Institution medical leadership may consult with MIS headquarters regarding staff member duties and quality of staff performance.
    - Determine institution MIS departments’ operating hours based on institutional needs.
    - Monitor performance of contractual and clinical onsite mobile service providers in collaboration with MIS headquarters.
    - Monitor performance of onsite medical imaging providers in collaboration with MIS headquarters.
  - Institutional radiology departments shall:
    - Ensure all patient medical imaging orders are entered into the Electronic Health Record System (EHRS) including orders for examinations to be performed onsite, verifying the orders in the CCHCS Radiology Information System (RIS), and ensuring all examination images are received by the CCHCS Picture Archiving and Communication System (PACS).
    - Perform all onsite X-Ray examinations.
    - Perform all onsite mammography ordered for screening and diagnostic purposes at women’s institutions, where available.
    - Ensure accuracy in all health records as they pertain to MIS.
    - Ensure appropriate maintenance of radiology department equipment.
    - Monitor mobile imaging technologist timeliness and adherence to State requirements.
    - Ensure mobile imaging technologists complete all steps in the examination process.
    - Report institution and mobile medical imaging equipment issues immediately to the CHSA, CEO and MIS headquarters.
    - Ensure the radiology department is current on X-Ray, mammography registration, inspections, and maintaining records of all required inspections, licenses, and permits.
    - Monitor the onsite schedule, obtaining results and examination images in collaboration with the Imaging Records Center.
  - The CCHCS contracted radiology group shall:
    - Interpret all onsite and mobile examination images loaded into PACS and contacting health care providers by telephone as clinically indicated.
    - Ensure availability to interpret images and to be contacted by the institutions Monday through Friday, between the hours of 7:00 a.m. and 7:00 p.m.
    - Perform annual RS&O and quarterly mammography inspections with a report of their findings to the inspected institution and Chief, MIS.
Procedure
- General Ordering Procedures
  - When a health care provider determines medical imaging is necessary, the health care provider shall submit an order for imaging in the EHRS and include the priority timeframe to complete the service.
    - For STAT X-Ray orders, the patient is immediately sent to the radiology department for the ordered service. For all other STAT imaging orders, the patient is immediately sent to an outside hospital.
    - All initial X-Rays are ordered as high priority and are provided as ordered or within 14 calendar days from the date of the order if a timeframe is not specified.
    - Medium priority medical imaging services shall be provided as ordered or within 15-45 calendar days from the date of the order if a timeframe is not specified.
    - Routine priority medical imaging services shall be provided as ordered or within 46-90 calendar days from the date of the order if a timeframe is not specified.
  - The ordering health care provider shall inform the patient of the plan including a general timeframe of expected service.
    - If a service is scheduled or rescheduled outside of compliance timeframes, the primary care team shall evaluate and inform the patient.
    - If the patient’s condition has declined and cannot wait for the scheduled appointment appropriate action shall be taken.
    - The information provided to the patient shall be documented in the EHRS.
    - The specific date, time, and location of an offsite appointment shall not be shared with the patient.
  - Orders for X-Ray examinations, abdominal ultrasounds, fibroscans, and mammograms do not require pre-authorization and will be automatically routed in the EHRS to the imaging scheduler.
  - Orders, other than X-Ray examinations, abdominal ultrasounds, fibroscans, and mammograms, will generate an electronic Request for Service (RFS) that requires Utilization Management (UM) pre-authorization as outlined in Section (c)(2) of this procedure.
  - Approved orders will be automatically routed in the EHRS to the imaging scheduler. The imaging scheduler shall determine if the examination will be performed onsite or offsite.
    - Onsite studies include Computerized Tomography, Magnetic Resonance Imaging, Ultrasound, mammography, and general X-Ray. Refer to the onsite scheduling process outlined in Section (c)(3) of this procedure.
    - Offsite studies include, but are not limited to, nuclear medicine, biopsy, and fluoroscopy examinations. Refer to the offsite scheduling process outlined in Section (c)(4) of this procedure.
- Pre-Authorization Process for Imaging Studies Ordered by CCHCS Providers
  - STAT orders are exempt from the pre-authorization process.
  - Orders, other than for plain film X-Ray examinations, abdominal ultrasounds, fibroscans, and mammography, are electronically routed to the UM nurse, or designee, for the first level review to determine if the RFS meets evidence-based clinical decision support criteria.
  - Upon completion of the first level review, the RFS will be electronically routed to the Chief Medical Executive (CME), Chief Physician and Surgeon (CP&S), or Supervising Dentist (SD) for second level review.
  - At their discretion, the CME, CP&S, or SD may obtain input from other health care providers at the regularly scheduled provider meetings to determine medical necessity. The decision-making authority to approve or deny the RFS at the second level remains with the CME, CP&S, or SD.
    - High and medium priority services shall be processed in a manner that allows for both the first and second level of review to be completed within five calendar days from the date of the order.
    - Routine priority services shall be processed in a manner that allows for both the first and second level of review to be completed within seven calendar days from the date of the order.
  - The Statewide Medical Authorization Review Team (SMART) is the third level of review and shall review cases appealed by the provider within 14 calendar days of the date of the order.
  - If the RFS meets clinical criteria and is approved, it will be automatically routed in the EHRS to the individual scheduling the appointment.
  - If the RFS is denied, the provider shall document the decision and provide the patient with alternate treatment strategies during the next encounter, which shall be within 30 calendar days of the denial of the medical imaging study.
  - Orders designated (DENTAL) shall only be utilized by dental providers and require prior approval by the SD or Dental Authorization Review Committee. These orders are not routed to the CME, CP&S, or Statewide Medical Authorization Review Team.
- Imaging Studies Completed Onsite or via Onsite Mobile Services
  - The designated staff shall schedule the appointment in the EHRS which interfaces with RIS and the Strategic Oversight Management System.
    - For STAT X-Ray orders, the patient is immediately sent to the radiology department for the ordered service, which shall be performed upon arrival of the patient in the radiology department.
    - Orders for all other medical imaging services shall be performed within the priority timeframes specified in Section (c)(1) of this procedure.
    - When a radiology scheduled procedure conflicts with another appointment, the individual scheduling the appointment shall communicate with the appropriate department prior to overriding the previously scheduled appointment.
  - The Radiologic Technologist (RT) shall check the order against imaging protocols to verify the proper examination was ordered. If a change is required, the technologist may change the order with a co-signature required from the ordering health care provider.
  - The RT shall communicate the necessary examination preparation to designated nursing staff per the institutional Local Operating Procedure (LOP). The designated nursing staff shall perform necessary patient examination preparation.
  - At the appointment, the RT shall:
    - Use at least two patient identifiers (e.g., patient name or ID card, California Department of Rehabilitation and Corrections number, date of birth) to positively identify the correct patient.
    - Arrive the patient in RIS.
    - Perform the requested service using established protocols.
    - Perform quality check of acquired images.
    - Submit the images to PACS for interpretation. Images are stored in the PACS.
    - End the appointment with clinically appropriate instructions to the patient.
  - The Radiologist shall read, interpret, and document results. The signed report is automatically transmitted to the EHRS and RIS.
    - All critical results shall be immediately communicated to the ordering health care provider via telephone. If the results are received after hours or the ordering health care provider is unavailable, the report shall be communicated to the Triage and Treatment Area (TTA) staff via telephone for appropriate notification to the on-call provider. (See Appendix 1, Communication Urgency Level for Radiologic Findings.)
    - STAT examination reports shall be read and finalized within two hours from the time the examination is available for interpretation.
    - All other examination reports shall be read and finalized within four hours from the time the examination is available for interpretation.
    - Addendum requests shall be completed within three calendar days of the request being placed.
- Imaging Studies Ordered Onsite and Completed Offsite
  - The designated staff responsible for scheduling shall:
    - Contact the offsite facility to schedule the appointment.
    - Request that upon completion of the exam, the offsite facility:
      - Immediately communicate all critical results to the TTA for appropriate action. (See Appendix 1, Communication Urgency Level for Radiologic Findings.)
      - Submit the interpretive report to the requesting institution within two business days of approval by the Radiologist.
      - Submit the images to the CCHCS Health Information Management (HIM) department within three business days.
    - Schedule the order in the EHRS.
    - Submit any related examinations or information to the offsite facility.
  - When a scheduled radiology procedure conflicts with another appointment, the individual scheduling the appointment shall communicate with the appropriate department prior to overriding the previously scheduled appointment.
  - The RT shall communicate the necessary examination preparation to Nursing (or designated) staff per the institution LOP. Nursing (or designated) staff shall perform and ensure patient preparation is completed including the communication of any related instructions the patient needs to receive.
  - The designated specialty clinic staff shall ensure all necessary arrangements are made for patient transportation to the offsite facility pursuant to the Health Care Department Operations Manual, Section 3.1.11, Outpatient Specialty Services.
    - Staff shall follow offsite specialty services workflow within the EHRS for patients undergoing offsite specialty radiology examinations.
  - The offsite report is received by the HIM department at the institution which shall be transmitted to the ordering provider for review and endorsement in the EHRS.
  - The HIM department moves the offsite report (PDF file) to the designated local “not completed” radiology folder. Institution radiology staff shall:
    - Upload or scan the report into the RIS.
    - Assign (create non-medical addendum for off-site) a RIS task for the Imaging Records Center.
    - Complete the exam.
  - The Imaging Records Center shall:
    - Request the images from the outside facility if they have not been received by HIM.
    - Upload the images into PACS and finalize examination.
- Imaging Studies Completed While Patient is Offsite at a Hospital
  - The corresponding offsite imaging report will be received by the HIM department at the institution within three days of discharge and made available to the provider and the radiology department.
  - The designated radiology staff shall:
    - Place an order and schedule it in the EHRS with the actual date of service,
    - Upload or scan the report into RIS,
    - Assign a task (create non-medical addendum for off-site) in RIS, and
    - Complete the exam for the Imaging Records Center.
  - The Imaging Records Center shall:
    - Request the images from the outside facility if they have not been received by HIM.
    - Upload the images into PACS and finalize examination.
- Provider Review of Imaging Studies Results and Patient Notification and Follow-up
  - Following the finalization of all imaging studies as described in Sections (c)(3) through (5) above, the health care provider shall:
    - Review and endorse the report within five calendar days of receiving an examination report notification into the EHRS.
    - Create a patient notification letter in the EHRS at the time of the provider’s review of the examination results. The patient notification letters shall include the following:
      - Date of the examination results.
      - Name of the health care provider who reviewed and endorsed the medical imaging result.
      - The clinical significance or meaning of the medical imaging results such as, but not limited to, whether the results are unchanged, or within normal limits, or as expected, or whether additional testing is required.
      - Whether a follow-up appointment with the provider is required and that it will be scheduled.
  - Patient notification letters shall be printed for collection by the designated staff member to be distributed to the patients.
  - Patients may request to view their detailed medical imaging records free of charge at their institution’s HIM office.
  - The Primary Care Team (PCT) shall schedule the patient for a follow-up appointment as clinically indicated. At the follow-up appointment, the designated PCP shall discuss the findings and recommendations with the patient and document the discussion in the EHRS.
- Imaging Study Cancel and Place a New Order
  - An imaging study may be canceled for reasons including, but not limited to, patient refusal, the study is no longer clinically indicated, conflicting appointments, or the incorrect study was ordered.
  - The designated health care staff shall cancel and place a new order in the EHRS with a co-sign, note the specific reason for cancellation, and notify the ordering health care provider via telephone and a message using the EHRS message center regarding the cancelled order.
  - The ordering health care provider shall sign-off on order changes or cancellation in the EHRS.
- Quality Assurance and Quality Control
  - Testing Equipment and Supplies
    - On a quarterly basis, satisfactory operation of all X-Ray equipment shall be checked by examining the following:
      - Equipment condition
        
        Each of the items listed in the quality control checklist below should be inspected by a RT on a quarterly basis or after service or maintenance on the X-Ray unit. Items not passing the visual check should be replaced or corrected as soon as possible.
        
        Mechanical Integrity
        
        Check for loose or absent screws, bolts, or other loose elements.
        
        Functioning of meters, dial, and other indicators.
        
        Collimator light brightness and cleanliness.
        
        Operation lights on control panel are sufficiently lit (illuminated) to function in a darkened examination room.
        
        Collimator beam limiting devices functioning correctly and verification of proper alignment to bucky devices.
        
        Mechanical Stability
        
        Locks and detents operable.
        
        Over-head X-Ray tube boom smoothness of motion.
        
        Table bucky devices and wall unit cassette holders are stable and move smoothly.
        
        If the X-Ray table has angulation functions, check the smoothness and accuracy of the angulations cable.
        
        Condition of cables termination rings are fastened, no insulation breaks, and they hang properly as to not interfere with the operations of the unit.
        
        Inspection of the condition of computed radiology (CR) or digital radiology (DR) cassettes and imaging devices.
        
        All lead or lead equivalent aprons and gloves, to include those in Dental, shall be checked annually by performing a radiologic image review to ensure no cracks or damage. All inspections shall be logged in the Annual Lead or Lead Equivalent Apron log in the Quality Control book kept in the radiology department.
        
        CCHCS shall contract with a medical physicist to perform annual testing of all required radiographic equipment as needed and mammography equipment, if applicable.
      - Equipment compliance with state regulatory provisions as required under Title 17 of the California Code of Regulations (CCR) 30305 and 30307. Technique charts shall be made available for each room to maintain consistent exposure factors and image quality.
  - Repeat Analysis
    - The criteria associated with repeating an exposure is subjective. Institutional radiology departments should strive for a repeat rate no greater than five to seven percent monthly and submitted to MIS.
      - Determine the total number of repeated exposures and the total number of exposures. The overall repeat rate is the total of repeated exposures divided by the total number of exposures during the tested period.
      - Repeat analysis should be performed quarterly and requires an ongoing tracking of number of exposures.
      - The repeat analysis report shall include each RT, modality, and exam procedure performed.
    - The percentage of repeat exposures shall provide the institutional radiology departments with information that focuses attention on the proper corrective action needed to reduce that percentage.
  - Artifact Evaluation and Prevention
    - All DR or CR cassettes and imaging devices shall be identified with a number placed on the back of each cassette for inventory and quality assurance tracking.
    - Identify and correct artifacts that may obscure clinical findings on radiographs.
    - DR or CR cassettes and imaging devices shall be charged (if applicable) as needed and cleaned according to manufacturer specifications.
      - Documentation of when cassettes, imaging plates, and imaging devices are cleaned. This must be maintained to ensure compliance with Title 17 of the CCR 30305 and 30307.
Appendices
- Appendix 1: Communication Urgency Level for Radiologic Findings
References
- California Code of Regulations, Title 17, Division 1, Chapter 5, Subchapter 4, Group 3, Article 4, Section 30305 and Section 30307
- Health Care Department Operations Manual, Chapter 3, Article 1, Section 3.1.11, Outpatient Specialty Services
- California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 9, Article 6, Sections 91060.1-91060.17, Radiology Services
Revision History
- Effective: 06/2012
  Revised: 09/17/2025

Appendix 1: Communication Urgency Level for Radiologic Findings

Anatomical Region	Category 1: Communicate Immediately (Call)	Category 2: Communicate Within Hours (Sign within 4 hours)	Category 3: Communicate Within Days (Sign within 4 hours)
General	∙ Malpositioned line or tube of immediate clinical concern (e.g., ET tube or enteric tube in bronchus) ∙ Foreign body with potential immediate and/or severe consequences ∙ Any finding that the interpreting radiologist determines requires immediate physician notification	∙ Clinically significant mass, tumor or infection ∙ Finding highly suggestive of malignancy ∙ Intravascular line in suboptimal location, moderate risk (e.g., Intended central line in jugular or azygous vein, right atrium) ∙ Retained surgical instruments, sponges, devices ∙ Misplaced or migrated surgical or other implanted devices (e.g., IVC filter, gastric band, pacemaker wires) ∙ Adverse event from diagnostic imaging or interventional procedure ∙ Significant congenital anomaly	∙ Probable malignancy, any location, no acute danger to patient ∙ Significant nonmalignant diagnosis, any location, no acute danger to patient ∙ Incidental finding on imaging study requiring further workup or longer-term follow-up
Neurologic/ Head and neck	∙ Intracranial or spinal hemorrhage (parenchymal, subarachnoid, subdural epidural) ∙ Intracranial mass with significant mass effect (midline shift/herniation/hydrocephalus) ∙ Brain herniation ∙ Symptomatic hydrocephalus (malfunctioning shunt or new diagnosis of any cause) ∙ Depressed skull fracture ∙ Posttraumatic pneumocephalus ∙ Arterial dissection ∙ Severe spinal cord compression of any cause ∙ Unstable spine fracture ∙ Cord hemorrhage or infarct ∙ Airway obstruction or impending obstruction (epiglottis, retropharyngeal abscess, tonsillitis, facial fracture, other)	∙ Critical arterial stenosis or occlusion ∙ Non-ruptured intracranial aneurysm ∙ Intracranial mass without significant mass effect (no midline shift/herniation) ∙ Non-hemorrhagic stroke, not thrombolytic candidate ∙ Linear skull fracture ∙ Facial fracture, no airway compromise, likely to need surgical repair ∙ Stable spinal fracture without cord compression ∙ Spinal mass without cord compression ∙ Spinal cord edema ∙ Discitis ∙ Airway narrowing, not severely obstructive ∙ Abscess, any location ∙ Encephalitis	∙ Small intracranial mass, likely benign, no mass effect ∙ Hemodynamically significant arterial stenosis (carotid or vertebral), not associated with acute symptoms or otherwise immediately threatening ∙ Suspected brain metastases, established cancer diagnosis
GI	∙ Unexplained pneumoperitoneum ∙ Closed loop intestinal obstruction ∙ Intestinal ischemia and/or portal/mesenteric venous gas ∙ Pseudoaneurysm or active hemorrhage (post trauma, GI bleed, other) ∙ High grade intra-abdominal organ injury (liver, spleen, pancreas, other) and/or bowel injury post trauma, acute intervention likely	∙ Abscess, any location ∙ Intestinal obstruction, no evidence of acute ischemia ∙ Intra-abdominal infection, likely surgical or interventional candidate (Appendicitis, cholecystitis, diverticulitis, abscess, other) ∙ Large volume ascites ∙ Low to moderate grade intraabdominal organ injury and/or bladder or bowel injury post trauma, observation likely ∙ Pneumatosis in bowel wall, no other signs of ischemia	∙ Low volume ascites (any cause), portal hypertension, and/or cirrhosis
GU/OB	∙ Testicular torsion ∙ Ovarian torsion ∙ Ectopic pregnancy (high likelihood) ∙ Placental abruption ∙ Uterine rupture ∙ High grade kidney injury and/or ureteral or bladder injury post trauma, acute intervention likely ∙ Absent perfusion postoperative kidney ∙ Oligohydramnios (less than fifth percentile for age)	∙ Placenta previa or suspected placenta accreta, increta, percreta in third trimester ∙ Embryonic/fetal demise ∙ Incompetent cervix in pregnancy ∙ Abdominal umbilical cord Doppler or IUGR ∙ Urinary tract obstruction (stone, tumor, other) ∙ Pyonephrosis/renal abscess ∙ Abnormal appearing pregnancy for which short interval follow-up is recommended ∙ Indeterminate findings for ectopic versus normal pregnancy	∙ Placenta previa or possible previa in second trimester ∙ Suspected placenta accrete, increta, percreta in second trimester ∙ Abnormal findings on routine obstetrical ultrasound (possible fetal abnormality, abnormal growth, abnormal fluid volume, other) not likely to need acute intervention
Breast		∙ Biopsy recommended	∙ Follow-up imaging recommended
MSK	∙Non-spinal fracture and/or dislocation with risk of vascular compromise ∙Necrotizing fasciitis		∙ Bone lesion at risk for pathologic fracture (femur, other) ∙ Non-spinal fracture and/or dislocation without vascular compromise, likely to need intervention ∙ Large hematoma without or with fracture, especially with compression of adjacent structures ∙ Fracture follow-up imaging, significant change in alignment or concern of infection ∙ Infection (including septic arthritis and osteomyelitis) ∙ SCFE ∙ Hardware complication
Chest	∙Tension pneumothorax ∙Pulmonary embolus (CT or high probability V/Q scan), hemodynamically unstable, central embolus, and/or extensive emboli ∙Lung lesion with high possibility of being active TB ∙Large pericardia effusion and/or suspected tamponade or any cause ∙Active posttraumatic hemorrhage ∙Tracheal obstruction or impeding obstruction	∙ Superior vena cava occlusion (including SVC syndrome)	∙ Pneumothorax, no evidence of tension ∙ Lobar or lung collapse ∙ Pneumomediastinum, interstitial emphysema, extensive subcutaneous emphysema ∙ Pulmonary embolus, hemodynamically stable, limited extent peripheral emboli ∙ Moderate or large pleural effusion ∙ Significant superior vena cava compression or narrowing ∙ Pneumonia
Cardiac/ Vascular	∙Ruptured/leaking arterial aneurysm (thoracic or abdominal aortic or other) ∙Limb-threatening arterial or venous occlusion or high-grade stenosis ∙Arterial dissection or intramural hematoma (aortic, other) ∙Acute myocardial infarction	∙ Hemodynamically significant arterial stenosis or occlusion, associated with acute symptoms ∙ Occluded coronary or other bypass graft with associated symptoms ∙ Deep venous thrombosis ∙ Arterial pseudoaneurysm post vascular access ∙ Thoracic aortic aneurysm ³ 6 cm or Abdominal aortic aneurysm ³ 5 cm, no evidence of acute instability ∙ Previously unknown chronic arterial dissection or intramural hematoma	∙ Nondisplaced minor fracture or questioned fracture low risk for worsening ∙ Routine fracture follow-up imaging, healing not progressing as expected or minor change in alignment