Checklist for X-ray Request Forms

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Radiology Department – Thamaga Primary Hospital CHECKLIST FORM FOR X-RAY REQUEST FORMS Reporting Period: …………………………………….. No. Reques t Form Ward Date Requestin g officer’s name Name of patie nt Age of patie nt SEX LNMP X-ray Requeste d Previ ous x-ray Clin ical hist ory Requesting officer’s signature

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xray request form audit tool

Transcript of Checklist for X-ray Request Forms

Radiology Department Thamaga Primary HospitalCHECKLIST FORM FOR X-RAY REQUEST FORMSReporting Period: ..No. Request FormWardDateRequesting officers nameName of patientAge of patientSEXLNMPX-ray RequestedPrevious x-rayClinical historyRequesting officers signature


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