X-ray Frequently Asked Questions - EH: Minnesota Department of Health

X-ray FAQs
Frequently Asked Questions

On this page
Converting from film to digital imaging
Records retention after MDH inspection
Disposing x-ray film
Shielding plan requirements
X-ray equipment registration
X-ray equipment sold or no longer used
X-ray equipment operators
Individual monitoring devices (dosimetry badges)

What must a registrant do when converting from film to digital imaging?

The following will ensure facility conversions will meet Minnesota X-ray Rules.

  • Exposing humans for training, demonstration or testing during the conversion to digital imaging is prohibited, and is subject to an Administrative Penalty Order.
  • You must notify MDH within 30 days of the conversion. Notifications can be sent via email to health.xray@state.mn.us.
  • You must follow the quality control recommendations of the digital system’s manufacturer when you have a computed radiography (CR) or a direct radiography (DR) digital imaging system, per Minnesota Rules, part 4732.0835.
  • Initial calibrations must be performed if the conversion to digital imaging includes new or replacement x-ray equipment.
  • Performance evaluations of your x-ray equipment must be performed, at the appropriate interval listed in Minnesota Rules, part 4732.1100, and when any maintenance is performed on the x-ray equipment.
  • All staff operating the x-ray equipment must be trained in the digital system’s use, including: Changes in technique factors used for digital imaging, quality assurance procedures for the use of digital imaging. Staff training must be documented according to Minnesota Rules, part 4732.0330.
  • Technique charts must be updated or replaced to reflect any changes in technique factors used for digital imaging.
  • Procedures must be updated to reflect the conversion from film to digital imaging.
  • Digital imaging manufacturer’s recommendations for use and quality assurance must be maintained and available to staff and for MDH inspection, including: Operation, maintenance, and troubleshooting information.
  • Registrants that use a combination of film and digital must comply with the applicable quality control requirements of each imaging system.

What records must a facility retain after an MDH inspection?

The MDH x-ray inspection is one piece of a facility’s regulatory and quality assurance puzzle. MDH x-ray inspectors review a registrant’s records generated between the previously completed inspection and the current inspection only. The exception to this would be the following: 

  • Training records must be maintained throughout the operator of x-ray equipment employment and until the first inspection after termination
  • Records of individual monitoring (dosimetry badges) must be maintained for 30 years, or the lifetime of the individual.

Record retention and review requirements for other regulatory agencies, accrediting agencies, or for corporate or self-auditing purposes may be different than the MDH X-ray Program’s minimum requirements. Consult with the appropriate agencies, the radiation safety officer, or administration before disposing of any records associated with your MDH x-ray inspection.
Minnesota Rules, part 4732.0330 has additional information on record and retention requirements.

When can a facility dispose of x-ray film?

Record retention and review requirements for other regulatory agencies, accrediting agencies, or for corporate or self-auditing purposes may be different than the MDH X-ray Program’s minimum requirements. These requirements may also include patient and quality control films. Below are some film retention requirements specific to the MDH x-ray rules. Consultation should be made with the appropriate agencies, radiation safety officer, or administration before disposing of any records associated with your MDH x-ray inspection.

Patient Films

  • The MDH X-ray Program does not have regulatory authority over patient films or records.
  • Recycle patient films as directed by the facility’s medical records retention policy.
  • For hospital films, refer to Minnesota Statutes, section 145.32 which outlines seven-year retention schedules. In the case of a minor, the retention is the age of majority (18) plus seven years.

Quality Control (QC) Films

  • Processor quality control films: Retain QC films for 60 days. The quality control charts (record results) must be maintained from inspection to inspection.
  • All other quality control records and film/images must be retained from inspection to inspection: Screen Contact, Speed Match, Fog Tests, Lead Apron Check, Training, X-ray Equipment Evaluations, and Digital Imaging - Manufacturer Recommended QC Tests.

Does MDH require a shielding plan?

Yes. Minnesota Rules, part 4732.0360  requires a shielding plan for:

  • New construction of an x-ray room/area. This includes rooms/areas that were not originally designed for x-ray use and are now used for this purpose.
  • A structural remodel of an existing x-ray room/area. Removal or remodeling of existing exterior walls, ceiling, floor, or control booth of a room or area.

Minnesota Rules, part 4732.0220 requirements include:

  • Registrants must maintain documentation of the radiation shielding installed in their facility.
  • Shielding plans be completed by a service provider or by a physicist

Submit the shielding plan to MDH:

  • Shielding plans should be submitted electronically to health.xray@state.mn.us
  • The facility will receive a letter from MDH stating that the plan was received
  • It is not necessary to delay construction once the shielding plan has been submitted to MDH

Go to > top

How is x-ray equipment registered?

A facility must be registered with the MDH prior to first use of x-ray equipment, including temporary use or demonstration. The facility must register any x-ray equipment the facility possesses by notifying MDH and completing the registration process.

NOTE: Service Providers are not registering the facility’s equipment. They are only required to notify MDH regarding installation or delivery of equipment. The facility must complete the registration.

The distributor or service provider is responsible to notify MDH of the sale, lease or transfer of x-ray equipment. The facility’s registration also includes a fee for the facility and for each piece of equipment.

What is required when equipment has been sold or is no longer used at a facility?

The facility must notify MDH when any equipment is disabled, transferred, or sold. Notifications can be sent via email to health.xray@state.mn.us.

Who may operate x-ray equipment on humans in Minnesota?

  • Licensed practitioners of the healing arts
  • Dental Assistants/Hygienists licensed with the Minnesota Board
    of Dentistry who are working within their scope of practice
  • ARRT Radiologic Technologists
  • ARCRT Chiropractic Radiologic Technologist
  • Individuals who have passed a Minnesota operator’s exam prior to Jan. 1, 2008
  • ARRT Limited Scope X-ray Operators. The individual must have passed the core exam and the modules specific to the anatomical areas they are imaging.
  • Licensed physician assistants with a valid physician-physician assistant agreement
  • Radiology Practitioner Assistant (RPA)
  • Registered Radiologist Assistant (RRA)
  • Nuclear Medicine technologists (ARRT, CNMT) limited to imaging directly related to the PET/CT or SPECT/CT procedure.

Externships: The individual must be in an approved training course. Only activities conducted within the scope of the training course may operate equipment. MDH must be notified of any sites offering externships. 

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

Dosimetry badges must be provided and used by any individual that is likely to receive 10% (500 mrem) of the 5.0 rem occupational dose limit for one year. Registrants who are not providing occupational staff dosimetry badges must perform an evaluation of their radiation safety program and implementation to ensure that occupational staff members are not receiving greater than 500 mrem in a year. The registrant must retain all records and procedures used in the evaluation process.

Go to > top

For questions, comments or feedback regarding the MDH X-ray Program, please email health.xray@state.mn.us or call 651.201.4545.

Updated Thursday, February 15, 2018 at 03:47PM