Diagnostic Imaging (DI)

Podiatrist Guideline for Diagnostic Imaging (DI)

Guiding Principles

1. Requesting general radiography studies allows for:
   • Increased efficiency in the delivery of primary health care to Nova Scotians.
   • Effective and efficient referral or clinical management of neuromusculoskeletal care with minimal delays to necessary patient care.
   • The ability of regulated healthcare providers to function within their scope of practice in Nova Scotia as part of healthcare teams to relieve pressure on existing resources.

2. The podiatrist must adhere to all standards, guidelines, and legislation related to personal health information, such as the Personal Health Information Act (PHIA).
3. Prescribing podiatrists must ensure they have the theoretical and practical knowledge to prescribe plain view radiographs safely and effectively.

Protocol

1. To become an Authorized Prescriber of DI, the podiatrist will apply to the College. See appendix C for requirements.
2. The podiatrist will ensure that radiation exposure is kept as low as reasonably attainable (ALARA). This will be done through thorough assessment and following principles and guidance consistent with current recommendations such as found at Choosing Wisely Canada and American College of Radiology. See appendix D for more resources.
3. The podiatrist will assess previous radiological studies within the past year to avoid unnecessary duplication of x-ray studies. Private sector podiatrists do not have access to the records system; this will require the client/patient be asked if they have had the radiograph already.
4. The podiatrist will complete and sign an approved NS Health/IWK Health radiology requisition including the following information:
   • general Radiography studies required,
   • relevant clinical background,
   • name and phone number/fax number of the requesting podiatrist to ensure timely communication of results, and,
   • name and phone/pager number of the patient’s MRHCP (most responsible healthcare provider, e.g., family doctor, nurse practitioner) if applicable.
5. The patient will be given the requisition and provided with the appropriate information to schedule an appointment.
6. Radiology reports will be sent by the DI department directly to the podiatrist, the client’s primary care provider, and any specialist identified on the requisition as appropriate. Results will be faxed to the appropriate private clinic indicated by the podiatrist.
7. After completion of the x-ray, the podiatrist may discuss the findings with a collaborating Physician/Nurse Practitioner in clinic, when appropriate.
8. In the case of findings that are out of scope and therefore require follow up by the patient’s MRHCP (most responsible healthcare provider, e.g., family doctor, nurse practitioner), the podiatrist will contact the MRHCP via fax or electronic transfer to ensure they received the report and confirm follow-up.
   • If the client does not have a MRHCP in primary care, the podiatrist will direct the client to the appropriate level of care (such as a primary care clinic or virtual care) along with a note indicating the concerns and referencing the x-ray report. Options for care are available via YourHealthNS.
   • The podiatrist may not comment on findings outside their scope of practice.

Responsibilities

1. DI staff are responsible for sending the general radiography studies report to:
   • the referring podiatrist via fax or electronic transfer, and
   • the MRHCP by fax or electronic transfer.
2. The podiatrist is responsible for communicating general radiography study findings that are within their scope of practice to the patient.
3. For findings that are not within scope of practice and/or require follow-up, the podiatrist is responsible for directing the patient to the appropriate level of care.

4. The podiatrist shall recognize and accept responsibility for the impact of conducting and requesting radiographic studies on the overall costs and sustainability of the healthcare system, including ensuring clinical necessity for all studies requested and that the results cannot be obtained from another source.
5. The College of Physicians and Surgeons of Nova Scotia (CPSNS) is responsible to:
   • provide and maintain a current list of registered podiatrists and submit to IMIT (Information Management and Information Technology – NSH) as the register changes;
   • ensure all registered podiatrists have required Professional Liability Insurance as per the CPSNS policy;
   • provide members any updated legislation, regulations, standards, and policies applicable to the referral of patients for general radiography studies in Nova Scotia; and
   • house the DI authorized podiatrist’s prescriber roster and ensure the list of registrants is available and updated and ensure IMIT has a current list of all registered podiatrists using the prescribed form.

Theoretical Knowledge

Podiatrists should only request radiography studies when they are able to demonstrate the below list of theoretical knowledge to the College upon request.

• The kinds of radiography studies that are within the scope of podiatry practice.
• The formal rules that govern the use of radiation on patients.
• The risks associated with subjecting patients to radiation for investigations.
• The indications and contraindications that should influence whether radiography studies should be requested.
• The appropriate study to request in the context of the patient’s condition and body part that needs assessment.
• The normal anatomy of the relevant body part that will be investigated: in the case of podiatry, structures of the foot only.
• The appropriate roles of the various health professionals involved in the process of requesting the investigation, (i.e., the podiatrist, whose role is to request the study, the radiographer, whose role is to perform the radiological procedure, and the radiologist, whose role is to interpret the investigation and provide a report to the individual who requested it)

See appendix D for useful resources available online.

Practical Knowledge

Podiatrists should only request radiography studies when they are able to demonstrate the below listed forms of practical knowledge to the College upon request.

• How the study they intend to request falls within their personal scope of practice and competence.
• The ability to identify patient specific indications or contraindications.
• The ability to assess the radiation load that their patients may have been exposed to, to determine that patients are not irradiated more than necessary.
• Practical knowledge relating to how radiography studies are requisitioned and what kind of information needs to be provided.

Podiatrists are only permitted to request specific radiological studies. For a complete list of the studies included see the attached Appendix B.

Appendix A – Procedure

1. The podiatrist is responsible to do the following:
   1. Consider the benefits, limitations, contraindications, and risks in determining whether the radiograph is required to reach an appropriate diagnosis, clinical impression, and/or plan of care.
   2. Take all reasonable steps to ensure no unnecessary duplication in the general radiography study within Nova Scotia Health/IWK
   3. Complete and sign a radiology requisition as provided by NSH/IWK and include the following information:
      • general Radiography studies required,
      • relevant clinical background,
      • name and phone number/fax number of the requesting podiatrist to ensure timely communication of results, and
      • name and phone/pager number of the patient’s MRHCP (if applicable).

Appendix B – Radiography Study Views within Podiatrist Scope

• Toes – AP/PA, Oblique, Lateral
• Foot – AP/PA, Oblique, Lateral
• Calcaneus – Axial and lateral
• Heel – Harris Heel
• Ankle – AP/PA, Oblique, Lateral

Appendix C – Requirements

1. Registrant in good standing licensed to practice with the College of Physicians and Surgeons of Nova Scotia.
2. Complete application that will include the following:
   • Attestation of competence
   • IM/IT form to be forwarded to the DI team by the College

Attestation of accuracy of the following:

• License #
• First Name
• Middle Name
• Last Name
• Clinic Name
• Office Address, Suite, City, Province, Postal Code
• Office Phone
• Office FAX
  • Required for receiving reports. Must be compliant with all health information standards, guidelines, and legislation
• ii. Critical Results contact number
  • In the event of a critical result requiring emergency care, the referring podiatrist is responsible for following up and ensuring the patient is informed and directed to the appropriate care. While this is not a frequent occurrence, the referring podiatrist is responsible for ensuring they have provided an effective contact number.

Upon approving the application, CPSNS will send any changes to NSH/IWK to update their system with the relevant details.

Appendix D – Additional Resources

• ACR Appropriateness Criteria® | American College of Radiology
• CAR_MSK_Referral_Guideline.pdf
• Recommendations – Choosing Wisely Canada
• Ottawa Ankle Rules – Physiopedia
• X-ray Radiographic Patient Positioning

Patient Education:

• Having an X-ray (nshealth.ca)

Relevant NSH/IWK Policies:

• Diagnostic Test Requests – Authorized Prescriber

Forms

• Diagnostic Imaging Request Form
• Request for Patient Health Care Information Form
  • Please note – when requesting reports of previously completed images it may take up to 30 days for some reports/images to be delivered depending on the number of requests received.

Document History

Approved by Executive Committee of the College of Physicians and Surgeons of Nova Scotia: May 7, 2025