College of Chiropractic Intern’s Clinic Handbook

9.0 Intern Use of XRAY

9.1 Guidelines for Performing Radiological Examinations

A radiological examination is performed to help identify or rule out clinically suspected abnormalities, including biomechanical alterations and pathology. Occasionally, as with a full-spine study for scoliosis, the examination may serve as a baseline for anticipated follow-up. The radiological examination should be based upon findings from a thorough history and physical examination.

  1. Examples of findings that may indicate the necessity for a radiological study include:
    • Biomechanical alterations or dysfunction
    • History of significant trauma
    • History of malignancy
    • History of fever or other findings suggesting active inflammation/infection
    • Night pain
    • Severe focal pain
    • Findings that may indicate a systemic disease with musculoskeletal manifestations
    • Clinically apparent scoliosis, especially in a skeletally immature patient
    • Patient over 40 years old, especially with no previous films of the area of interest
    • Evidence of visceral involvement
    • Abnormal laboratory findings
    • Clinician's intuition/suspicion for radiographically demonstrable abnormality that may significantly alter diagnostic or therapeutic approach.
  2. Examinations should be chosen based on the careful analysis of projected risks vs. benefits of the study. Radiological studies should always provide maximum information at the minimum radiation dose to the patient. The following questions should be answered:
    • Does the patient have a health problem requiring a radiological examination?
    • Could the examination provide essential information that may significantly alter case management?
    • Does the iatrogenic hazard of the study outweigh the benefits of the procedure?
    • Could another examination or imaging procedure be warranted?
  3. Generally, a minimum of two opposing views at 90 degrees to each other are required to adequately image a body region. Partial or incomplete studies are a liability and are unacceptable. Interns will receive no credit for incomplete studies. Appropriate shielding and filtration should be used whenever indicated, unless this will interfere with the purpose of the study.
  4. The patient should always be clearly informed of the need and purpose for the radiological examination. Interns should discuss with their faculty clinician who will be informing the patient of the need and purpose of the examination, and whether or not there are contraindications to the procedure. Most offices have a form to be signed by female patients indicating that they are not pregnant.
  5. The patient's privacy is to be guarded at all times. No unnecessary personnel and no other patients should be in the area of the radiology suite at the time of the examination.

9.2 Ordering the Radiological Examination

The following are guidelines for ordering a radiological examination:

  1. Only a licensed physician, i.e. a faculty clinician, may order a radiological examination. This will be done in consultation with the attending intern.
  2. Minors must have a signed consent form from a parent or guardian prior to any radiological examination. Patients may, on occasion, refuse the study. A second explanation of the need for the study may convince the patient, but attempts at coercion or forceful persuasion on the part of the intern are inappropriate and unprofessional in these instances.
  3. If a patient refuses a radiological examination, the faculty clinician will make a decision whether treatment will continue. Failure to x-ray before treatment could result in a malpractice claim if, for instance, a fracture was not diagnosed and injury resulted. If treatment does continue, it should be clearly noted in the file that the patient refused x-rays and the potential consequences were explained. Have the patient initial the notation.
  4. It is a state law that the clinical indication for ordering the study be clearly stated in the patient’s file and a licensed doctor must authorize any radiographic study.
  5. All patients should be properly attired prior to the radiological examination, and proper shielding should be utilized.
  6. At all times, treat the patient with courtesy and respect. Be mindful of patient modesty when accompanying them to and from the x-ray suite.

9.3 Intern Credit for Radiological Examinations

Under MN state law, only licensed chiropractors and Certified employees can take x-rays. Interns, in our educational program, may take x-rays under the direct supervision of either party listed above, and can receive tech credit when participating in this procedure.

The T7 – T10 interns will receive credit only for complete radiological examinations and reports that are submitted in eMedley.

Assessment will be made by the faculty clinician based on the following:

  1. The complete history and factors used in the study must be recorded on the X-ray Studies form, which has been reviewed and signed by the faculty prior to the study. The faculty will evaluate this step.
  2. The film must be diagnostic. Non-diagnostic films must be repeated before the faculty will issue credit for the examination.
  3. The intern, after completing the X-ray Studies form, meets with their faculty clinician to review the x-rays and report. The faculty clinician will approve the report on eMedley, when they are assured of its accuracy and completeness.
  4. Radiology Tech Guidelines  

The X-ray Studies form must be approved in eMedley by the intern’s faculty clinician for the intern to receive tech and/or report credit.

Please Note: Tech credit will be issued according to the following definitions.

Cervical

LCN and APLC with or without APOM = 1 tech

LCE, LCF; and RAO, LAO or RPO, LPO = 1 tech for either/both

Davis series = 2 techs

Swimmer's view = 1 tech

Thoracic

APT and LT = 1 tech

Ribs = 1 tech

PA and lateral chest = 1 tech

Lordotic chest = 1 tech

Lumbar

APLP and LLS = 1 tech

LLE, LLF; RAO, LAO or RPO, LPO; and R & L lateral bending views = 1 tech for each

Frontal angulated LS spot or lateral LS spot = 1 tech

Sacrum/Coccyx

Sacrum: AP and lateral = 1 tech

Coccyx: AP and lateral = 1 tech

Spinal survey

APFS (with closed mouth positioning) and 3 sectional lateral views with or without APOM = 2 techs. A separate APOM view completes the full spine study. AP & LAT FS = 1 tech. Only if taken as an intern fulfilling his or her clinic assignment at a credentialed CBI clinic at which the AP & LAT FS films are the designated policy and procedure. The faculty clinician is responsible for clinical decision-making and quality assurance.

Abdomen AP abdomen = 1 tech

Upper extremity

Internal/external rotation and baby arm shoulder = 1 tech

R & L AP weighted and non-weighted AC joint = 1 tech

AP and lateral elbow with or without oblique and Jones (tangential) = 1 tech

PA and lateral wrist with or without oblique and PA with ulnar deviation = 1 tech

PA and oblique hand = 1 tech

PA and lateral fingers or thumb with or without oblique = 1 tech

Lower extremity

AP pelvis with or without one hip film = 1 tech

AP and frog leg hip = 1 tech

AP and lateral knee with or without tunnel and sunrise (tangential) views = 1 tech

AP and lateral ankle with or without oblique = 1 tech

Inversion/eversion (stress views) ankle = 1 tech

AP and oblique (and optional lateral) foot or toes = 1 tech


Report credit shall be issued in the same manner as x-ray techs (i.e. if a report is completed on a Davis series, it is worth 2 report credits).

9.4 Digital x-ray

Your faculty clinician’s office may utilize a digital x-ray system. In this case, the attending intern will receive tech credit for setting-up the patient and taking the x-ray.

9.5 State Regulations

It is the intern's responsibility to become familiar with the state regulations regarding conduction of a radiological examination. Regulations should be kept on file at the intern’s assigned clinic.

State regulations also require interns to complete an X-ray Technology Orientation before using an x-ray unit for the first time. Interns assigned to a college-owned clinic will receive training from the University Radiation Safety Officer.

CBI and MN T10 interns/externs must complete the X-ray Technology Orientation form and have it signed by their faculty clinician each term, regardless of whether they stay at the same site as the previous term or switch to a different clinic site.