INDEPENDENT HEALTH FACILITIESPACS QUESTIONNAIRE/CHECKLISTDIAGNOSTIC IMAGING / NUCLEAR MEDICINE /MAGNETIC RESONANCE IMAGING / COMPUTED TOMOGRAPHYNOTE: This document must be completed by the PACS System Administrator (SA).Quality AdvisorDateLicenseeDatePACS AdministratorDateAssessors will verify that information provided in the Pre-Visit Questionnaire is accurate and meetsPACS Facilities Standards and Protocols.PACS Questionnaire/Checklist – February 12, 2020Page 1 of 9

FACILITY TO COMPLETEC CompliantN/C Non-CompliantN/A Not ApplicableEQUIPMENT1.ASSESSORS TOCOMPLETE ONLYCN/CN/AFacility Responses(please complete within the space provided)a. What RIS System is in place?b. What PACS System is used?c. What modalities are on PACS?d. What modalities are not on PACS?e. Do all modalities on PACS haveDICOM modality work lists?f.Is there a system (please name) thatincludes exam ordering, schedulingand patient tracking?g. Is there short term data storage?h. Is the (short) term data storageduplicated? If so, where?i.Where is long term data storagekept?j.Is long term data storage duplicated?If so, where?k. Is the data backed up daily?2.Can patient identifying markers beremoved from the digital images tomaintain patient confidentiality, e.g.,when used for educational purposes?3.Is there a service contract for PACS?4.Is there software to view and correctpatient demographic/identificationerrors?5.Are there monitors for technologists andstaff to review exams as needed?PACS Questionnaire/Checklist – February 12, 2020Page 2 of 9

FACILITY TO COMPLETEASSESSORS TOCOMPLETE ONLYCPORTABILITY OF INFORMATION1.N/CN/AFacility Responses(please complete within the space provided)a. Can the PACS create copies (e.g.,burn a CD) for patients to take forcontinuing care / other healthcare provider? If not, where is thisdone?b. Does the DICOM exam burned toCD include scanned documents?(Scanned documents e.g.Technical impressions should beexcluded in PACS, however a copyof the final report should beprovided to the patient asneeded.)2.Does the CD produced contain aviewing program to launch theimaging exam from a PC? If so, what isit?3.Does the PACS have the ability to viewand/or import CD’s from otherproviders?4.Does the PACS have the ability toforward imaging studies to a LHINrepository?PACS Questionnaire/Checklist – February 12, 2020Page 3 of 9

FACILITY TO COMPLETEASSESSORS TOCOMPLETE ONLYCSECURITY/PRIVACY1.Does the PACS meet current Ontarioprivacy legislation (PHIPA)?2.Is the PACS SA role login passwordprotected?3.Are individual passwords required tolog on to a review station?4.Are passwords programmed toexpire? If so, how often?5.If teleradiology is used, is the transferof images and data via a secure line?i.e., VPN, Is it password protected?6.Is the number of images per seriesand matrix size visible on the image?N/CN/AFacility Responses(please complete within the space provided)PACS Questionnaire/Checklist – February 12, 2020Page 4 of 9

FACILITY TO COMPLETEASSESSORS TOCOMPLETE ONLYCREPORTING ENVIRONMENT1.Is Teleradiology used?2.Does the PACS SA verify the offsitereporting configuration for eachinterpreting physician?3.Does the PACS SA verify that offsitereporting monitors are checkedannually? (e.g. luminescence)4.What is the onsite reporting monitorsolution/setup? (Resolution, Number,indicate if color is available)5.What is the reporting structure of thefacility on a day to day basis? e.g. OneRadiologist on site, another at homevia Teleradiology for verbals etc.6.Are there 2 monitors available forsimultaneous comparison of studies?7.If Ultrasound or Nuclear Medicinestudies are reported, are colourmonitors/work stations available?8.Is the system “user friendly” to allowthird party interpretation?9.Does the system allow useradaptability, e.g. screen layouts etc.?N/CN/AFacility Responses(please complete within the space provided)10. Are the monitors of medical graderesolution and luminance?PACS Questionnaire/Checklist – February 12, 2020Page 5 of 9

11. Does the PACS have the following basic functionality?a. Panb. Zoomc. Measurements (and angles)d. Window level and widthe. Inverting gray-scalef. CT Hounsfield unitsg. MPR – Multiplanar Reconstruction (CT)12. Do all images show patientinformation as per guidelines?13. Is the number of images per seriesvisible on the study?14. Is kVp and mAs “available” on images15. Are the following available at the time of reporting?a. Requisitionb. Technologist work sheets (e.g.questionnaires, technical impressions)c. Previous reports (for comparison)d. Previous images (for comparison)16. a. Is there a system in place to mark andobtain verbals and urgent findings?b. Explain the verbal process from orderto referring physician receiving thereport.c. What is the process to obtain a verbalreport (“urgent” finding) when aRadiologist is not scheduled. e.g. afterhours, evenings, weekendsPACS Questionnaire/Checklist – February 12, 2020Page 6 of 9

FACILITY TO COMPLETEASSESSORS TOCOMPLETE ONLYCQUALITY ASSURANCE1.Is there a PACS System Administrator(SA)? (Please provide the name of theon-site person responsible). (If the IHFhas more than one site, a designatedPACS System Administrator mayservice more than one site).2.Has the PACS SA had specificequipment or vendor training?3.Is the PACS SA part of the QualityAssurance Committee?4.Is there a mechanism in place to:N/CN/AFacility Responses(please complete within the space provided)a. Allow interesting exams to bemarked?b. Verify completeness of datatransfer?c. Verify if exam has been reported?d. Is a teaching file available andeasily retrievable for teachingpurposes?PACS Questionnaire/Checklist – February 12, 2020Page 7 of 9

FACILITY TO COMPLETEASSESSORS TOCOMPLETE ONLYC5.Are the monitors checked annually forluminescence? How is this done?6.Are there written procedures in place in regards to:N/CN/Aa. Daily/weekly system checks?b. Verbal reportsc. Passwords?7.Are there written procedures in place regarding backups for the following?a. CD burner not functioningb. Modality worklist not functioningc. Modalities not sending to PACSd. RIS not functioning?e. Long Term storage not functioningf. Teleradiology not functioningPACS Questionnaire/Checklist – February 12, 2020Page 8 of 9

Comments: to be completed by assessorRecommendations: to be completed by assessorAll recommendations from EQUIPMENT; PORTABILITY OF INFORMATION; SECURITY/PRIVACY;REPORTING ENVIRONMENT; QUALITY ASSURANCE to be added to the final assessment report.PACS Questionnaire/Checklist – February 12, 2020PrintSavePage 9 of 9

PACS System Administrator may service more than one site). 2. Has the PACS SA had specific equipment or vendor training? 3. Is the PACS SA part of the Quality Assurance Committee? 4. Is there