Radiology Documentation Standards

1. Documentation in SystmOne

All internal X-ray requests & processing must be initiated and completed through SystmOne. External referrals do not use SystmOne for ordering but still require a patient status update upon completion.

1

Order Creation

• Doctor initiates request via the Create Order interface from the Toolbar or Order Request Overview Page.
• Choose appropriate site for x-rays
• All x-ray order must be done via SystmOne, no manual order is allowed to make sure every DICOM data is stored seamlessly.

2

Generate X-ray Word Template

Fill up mandatory fields in the form:

• Site of x-ray
• Clinical Indication/Diagnosis
• LMP for childbearing women Save the form using Save For Future Editing button.

3

Checklist Update

Doctor must update the patient checklist with order test name before directing the patient to Room 7

Visit Checklist

4

X-Ray Imaging Procedure In Progress

Radiographer proceed with imaging procedures and protocol

5

Order Completion

Radiographer marks ORDER COMPLETED in the Request Order Overview page after DICOM transfer to Orthanc PACS↴

6

Screenshot Backup

A JPG screenshot of the X-ray image must be uploaded to the patient's SystmOne profile as secondary backup

IMAGE PRINTING POLICY

• X-ray films are only printed for (1) referrals to ED or (2) Specialist Clinics and for (3) external referral patients returning to their originating clinic.
• Internal patients review images via Orthanc PACS — no film printing required.

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2. Patient Status in SystmOne

Status	Triggered By	When
🟣 In Progress	Doctor	Patient is in consultation; X-ray being considered
🟢 Sent for Diagnostic	Doctor	ORDER created and patient profile SAVED in SystmOne
🟡 Returned from Diagnostic	Radiographer	After image acquisition and ORDER COMPLETED marked

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3. Orthanc PACS — Image Storage

SystmOne does not integrate natively with the clinic's PACS. While SystmOne supports basic JPG/PNG attachments, this method is insufficient for clinical radiological review. KK Bandar Maharani uses Orthanc PACS↴ as the primary imaging platform for DICOM files.

Orthanc PACS Workflow

Storage Format

DICOM — maintains superior image quality and supports zoom, contrast adjustment, and measurement tools

Transfer

Radiographer transfers finalized DICOM from the Fujifilm CR System to Orthanc PACS Desktop (localhost server)

Access by Doctors

Doctors access and review images via the local Orthanc web interface — search by patient IC number

Backup

Screenshot of X-ray uploaded in JPG format to the patient's SystmOne profile

External Referrals

Film printed and handed to patient to bring back to the referring clinic — no PACS transfer for external cases

This dual-system approach maintains clinical documentation continuity in SystmOne while leveraging Orthanc PACS for proper radiological management and archiving.

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4. Examples of Documentation Errors in Radiology Unit

Error	Risk	Corrective Action
1. Missing indication or incomplete request fields	Wrong exam execution or delayed care	Return for completion before imaging
2. Identity mismatch across systems	Patient safety incident	Stop process and re-verify identifiers immediately
3. DICOM transfer not verified	Study unavailable for clinical decision	Validate Orthanc visibility before case closure
4. Delayed downtime reconciliation	Audit and continuity gaps	Complete backlog and document reconciliation time