X-ray Frequently Asked Questions

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What happens when we go digital?
What do we do with records after an MDH inspection?
When do we dispose of our facilities x-ray film?
When will we be inspected?
How do we register X-ray equipment
Who can take X-rays on humans in MN?
Who can order X-rays for humans in MN?
Who must wear film badges?

What happens when we go digital?

When your facility goes digital, you will need to do the following:

  • Make sure all of your staff who are performing x-rays are trained and the training is documented.  If you do a train-the-trainer type set-up, make sure this training is documented as well.
  • Technique charts will need to be corrected to ensure they indicate you are using digital.
  • Update your radiation manual. Ensure there is a copy of your digital software and digital sensor (or CR system) manual available for inspection. Resources need to be available on-site that allow for operator troubleshooting and outline QC requirements. 
  • Review the set-up, maintenance, and troubleshooting areas of these manuals in detail. If there is any routine maintenance of the digital system that may affect dose, you will need to perform these items and document them appropriately.
  • Consider writing new procedures that outline what steps staff should take if they have a problem with the digital system (i.e. do not x-ray the patient further, contact you, contact doctor, call the x-ray service provider, etc).

What do we do with records after an MDH inspection?

The MDH x-ray inspection may only be one piece of a facility’s regulatory and quality assurance puzzle. It is not possible for MDH to describe the records that facilities may destroy. Agencies such as OSHA have retention schedules that may be more detailed and require facilities to keep records indefinitely. In other words, MDH has record retention requirements ¬†which may or may not mirror other agencies. The following are two examples of MDH record retention requirements:

  • MDH requires that training records must be maintained throughout the employment of the x-ray operator and until the first inspection after termination
  • Records of individual monitoring must be maintained for 30 years or the lifetime of the individual, for example, film badges

Review 4732.0330, Subp. 4 to gain a clearer view of the records that must be maintained for MDH and then check with the facility information officer or radiation safety officer for further guidance. The old adage of “When in doubt, throw it out” may not be the best answer.

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When do we dispose of our facilities x-ray film?

We hear this question a lot, so we know there is some confusion among registrants as to when to dispose of their x-ray film.  Here are some general rules based on the type of film:

Patient Films:  Patient films should be disposed of as directed by your facilities medical records retention policy. For hospital films, please refer to Minnesota Statute 145.32. The statute states to keep films for seven years, or in the case of a minor, the age of majority (18) plus seven years. 

Quality control films:  Quality control films are films done daily to check the processor. They need to be retained for 60 days and the quality control charts (paper) need to be kept from inspection to inspection.

Screen contact, speed match, fog tests and any lead apron check films:  These types of film are kept from inspection to inspection.

If you’ve gone digital:  Please notify the X-ray Unit via mail or email that your facility has gone digital.  Your facility can discard quality control, screen contact, speed match and fog films, but must retain the lead apron check films from inspection to inspection.

When will my facility be inspected?

This depends on your last inspection, the general geographic location of your facility, MQSA (Mammography) inspections, the time of the year, and the weather.  We try to inspect facilities every four years and have multiple inspectors assigned to a geographic area (SE, NW, etc.) at any given time. Weather is a factor as to when we inspect facilities and unpredictable weather conditions in Minnesota can often change our schedules. In the winter when the weather is bad, we would not inspect facilities that would require our inspectors to drive long distances in dangerous weather conditions. MQSA inspections also affect our regular inspection schedule. Several inspectors are qualified Mammography inspectors and can sometimes perform state inspections in conjunction with their annual MQSA inspections.

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How do we register X-ray equipment?

  • If new construction or facility, complete shielding plan review prior to construction for MDH approval
  • Fill out registration forms provided by MDH, include appropriate fees
  • Schedule an appointment with a registered service provider to have an equipment performance evaluation performed prior to patient use
  • Have the Radiation Safety Officer (RSO) train staff on the use of the new equipment. Document the training session.
  • Perform all necessary quality control tests on any ancillary equipment prior to patient use
  • Update technique chart and post next to console
  • Dispose of old equipment properly. Check with your county regarding specifics.

Who can take X-rays on humans in MN?

  • Licensed practitioner of the healing arts
  • Dental Assistants/Hygienists licensed with the Minnesota Dental Board
  • ARRT Radiologic Technologists
  • ARCRT Chiropractic Radiologic Technologist
  • Individuals who have passed a MN operator’s exam prior to Jan. 1, 2008
  • ARRT Limited Scope X-ray operators (limited to the anatomical modules they have passed)
  • North Dakota operator’s exam (Written and 3-month clinical competency completed. The clinical competency cannot be completed in Minnesota.)
  • Physician assistants with a valid physician-physician assistant agreement
  • Radiology Practitioner Assistant (RPA)
  • Registered Radiologist Assistant (RRA)
  • Nuclear Medicine technologists (ARRT, CNMT) can do PET/CT or SPECT/CT.  
  • Externships:  Approved programs must notify the commissioner of the sites used for externships.  Those students must be supervised during their externship.

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Who can order X-rays for humans in MN?

  • Licensed practitioner of the healing arts.
  • Physician assistants with a valid physician assistant agreement.
  • Radiology Practitioner Assistant (RPA) with a valid supervisory agreement.
  • Registered Radiologist Assistant (RRA) with a valid supervisory agreement.
  • Advanced Practice Registered Nurses: Clinical nurse specialist, nurse anesthetist, nurse-midwife or nurse practitioner. 
  • Dental Hygienist under a collaborative agreement with a supervising dentist.

Who must wear individual monitoring devices such as film/personal dosimetry badges?

If you are likely to receive 10% of 5 rem in one year or a facility doing fluoroscopy, you will need to wear them. Generally, most offices will not need to provide monitoring devices.

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Updated Monday, 30-Sep-2013 11:10:39 CDT