Transfer of radiographs

Abstract

Dental radiographs constitute 25% of all exposures made in the UK and therefore in terms of radiation protection the population risk is not insignificant¹. Paragraph 11 of The Core of Knowledge in the Schedule to the Protection of persons undergoing medical examination or treatment (POPUMET) regulations² specifies the importance of using existing radiological information, whether films or reports, about a patient. The Guidance Notes³ recommends that in order to reduce unnecessary radiographic examinations, there should be ready availability of previous radiographs. Access to previous radiographs is also commended by the National Radiological Practice Board (NRPB) and the Royal College of Radiologists (RCR) in their report on Patient Dose Reduction in Diagnostic Radiology⁴. In addition to dose limitation, patient care is improved.

Main

The Joint Working Party (JWP) of the RCR and NRPB in their report on Guidelines on Radiology Standards in Primary Dental Care¹ endorsed the need for ready transfer and, where appropriate, return of radiographic records between clinicians as a means of improving patient care, for instance in monitoring the progression of dental diseases. However, the JWP recognised that there may be a conflict between this and other requirements to retain radiographic records. The report recommended that by 1998 a mechanism should be devised whereby this conflict of interest could be resolved. No progress has been made on this issue and the aim of this paper is to review the current state of affairs.

There are three distinct issues, ownership of radiographs, retention of radiographs and transfer of radiographs.

Ownership

Radiographs taken in NHS institutions are the property of the Secretary of State. General dental practitioners providing treatment under either a NHS or private contract own the radiographs. In both cases the patient pays for the opinion, not the radiograph.

Radiographs taken in NHS institutions are the property of the Secretary of State: their care is vested in the local Health Authority or Trust. General dental practitioners providing treatment under either a NHS⁶ or private contract own the radiographs. In both cases the patient pays for the opinion, not the radiograph⁷.

Retention

The General Dental Council states that dental records and radiographs should be retained⁸. The legal situation was reviewed by the Royal College of Radiologists in 1995⁵. In their view, the radiographs are the transitory part of the patient record whereas the radiology report is permanent and should be retained in the case notes. In dentistry, the advice offered is conflicting. In the general dental services, practitioners are required to retain records, including radiographs, for two years after completion of treatment⁶. The British Dental Association (BDA), citing the Consumer Protection Act, recommends 11 years from the date of the patient's last visit. In the case of minors, radiographs should be retained until the age of 25 or for eleven years, whichever is the longer⁹. The Dental Protection Societies dispute this and in their view records and radiographs should be retained as long as possible¹⁰.

There are two critical problems in retaining radiographs. First, a substantial proportion of GDPs' radiographs are of less than archival quality due to poor processing and will rapidly discolour. Further, we have no information on the likely lifespan of current emulsions. Second, while an increasing number of practitioners are mounting intraoral radiographs, many continued to use small envelopes from which radiographs are readily lost or misfiled. Panoramic radiographs are not always inscribed with the patient's name and date. If radiographs are to be retained forever then these problems, which are matters both of standards and risk management, must be resolved first.

Transfer of radiographs

There are a number of ways in which the transfer of radiographs can be achieved. They should not be given directly to the patient. Radiographs can be copied: this is commonplace in the United States. Copies can be obtained from most radiology departments in general hospitals for a small fee. Practitioners may or may not decide to pass the charge on to the patient, as the case may be. Alternatively, a suitable American desk-top copier is available in the UK (Dentsply, Weybridge, Surrey). Double pack film is recommended¹¹, but the size is limited to intraoral radiographs. It is also possible to transfer the image electronically either as a direct digital file or indirectly having been scanned first.

The third option is to loan radiographs. The BDA¹² encourages dentists to transfer radiographs wherever appropriate, ensuring that the receiving dentist will retain and return them should they be needed for future medicolegal reasons. The Dental Defence Union states that it is quite reasonable to let the patient's new dentist see previous radiographs on a loan basis if copies cannot be readily obtained; these could be sent direct to the new dentists on request who would in turn agree to keep them safe and return them as soon as possible¹⁰.

GDPs report two problems in loaning radiographs to hospitals. They believe that hospitals prefer to take their own radiographs and second, if they send their own radiographs, the hospital never returns them. The first statement is based on a misconception: hospitals would prefer not to repeat GDPs' radiographs, but often the image quality is such that they have no alternative. The second complaint is more justifiable: hospitals should as a matter of course and courtesy return GDPs' radiographs. With regard to loaning radiographs to other GDPs, practitioners believe they risk being sued because of the other dentist's findings. This problem, however, is inherent in general dental practice whenever a patient changes dentists. Diagnostic radiology is not an exact science. A substantial literature on this topic has accumulated over the past 50 years¹³. The same practitioner may not necessarily make the same diagnosis on each occasion nor will a group of practitioners agree among themselves. Variation is not necessarily an error. Some practitioners also claim it is more convenient to take their own rather than obtain any previous radiographs, despite the obvious disadvantages in terms of patient management and unnecessary exposure.

What is the solution? It is clear from the above discussion that the transfer of dental radiographs is hampered by misinformation compounded by apprehension. The solution depends on risk management and education. First, practitioners should write a contemporaneous report in the patient's record. This is simple risk management and recommended in other clinical situations, such as a fracture of a root canal instrument. The increasing use of records and radiographs as means of quality assurance provides further impetus for this practice¹⁴. Second, the case for loaning radiographs set out here should be widely discussed, for instance in POPUMET courses.

We should be reassured by our American colleagues in a country characterised by a high level of geographic mobility. They are at greater risk of litigation, yet have no qualms about making their radiographs available for patients to take to their next practitioner.

We should be reassured by our American colleagues in a country characterised by a high level of geographic mobility. They are at greater risk of litigation, yet have no qualms about making their radiographs available for patients to take to their next practitioner.

In conclusion, ready transfer of dental radiographs does not post an insuperable problem. With a clear understanding of the issues, it is possible to reconcile the apparently conflicting requirements of the parties involved.