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Radiology Documentation Standards

TL;DR

All internal X-ray orders must be created via the SystmOne Create Order interface — no manual forms. Complete the X-ray Word Template with mandatory fields, update the patient checklist, and mark ORDER COMPLETED after DICOM transfer. A JPG screenshot is uploaded as secondary backup.


Documentation Workflow

Every internal X-ray request follows this sequence from order initiation through to completion and backup.

1

Order Creation

  • Doctor initiates request via the Create Order interface from the Toolbar or Order Request Overview page.
  • Choose the appropriate site for the X-ray.
  • All X-ray orders must be done via SystmOne — no manual orders are permitted. This ensures every DICOM study 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 women of childbearing age Save the form using the Save For Future Editing button.
3

Checklist Update

Doctor must update the patient checklist with the ordered test name before directing the patient to the Radiology Unit.

4

Order Completion

Radiographer marks ORDER COMPLETED in the Request Order Overview page after the DICOM study is transferred to the PACS.

5

Screenshot Backup

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


Patient Status Transitions

The patient's status in SystmOne is updated at each stage of the radiology workflow to reflect their current location and care phase.

StatusTriggered ByWhen
🟣 In ProgressDoctorPatient is in consultation; X-ray being considered
🟢 Sent for DiagnosticDoctorORDER created and patient profile saved in SystmOne
🟡 Returned from DiagnosticRadiographerAfter image acquisition and ORDER COMPLETED marked

Image Printing Policy

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

Contributor

Dr Fuad Jaafar

Dr Fuad Jaafar

Facilitator, CCMS • KK Bandar Maharani

84 contributions

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Page info

Reviewed Jun 2026
Next review Jun 2027
JXR Nooraini bt Othman

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