MEDICAL IMAGING REQUEST Townsville Hospital & Health Service
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MEDICAL IMAGING REQUEST Townsville Hospital & Health Service X-ray - CT - Ultrasound - Nuclear Medicine - MRI - Fluoroscopy - Angiography The Townsville Hospital - IMB 47 100 Angus Smith Drive, Douglas, Qld. 4814 Ph: 07 4433 1500 Fax: 07 4433 1501 (external use only) URGENT REQUESTS - Please contact Radiology Material Number: 10150475 Form Revision: March 2013 DNA Rebook On Hold Cancelled Int: Appt Details: Clinical History & Provisional Diagnosis: (Include relevant surgery, imaging and pathology results.) Pregnant? Yes / No Infectious? Yes / No Allergies? Yes / No - Specify: MANDATORY INFORMATION FOR ACCEPTANCE OF THIS REQUEST UR: Surname: Given Name: DOB: / / Phone: Home Address: Requested Examination: Female Ward: Bed No: Clinic: Consultant / Specialist MO Full Name (Print) Consent Obtained? Interventional Procedure Renal Impairment General Anaesthetic Requested by: (Print Full Name) Declaration: I consider the benefits of the examination justify the risk to the patient. Signature: Contact: Ph: Pager: Billable Patient Dr Provider Number: Date: / / Date for next clinical review: / / Forward Additional Report to: Name: Address: Male Room: Acc No: Scan to QRIS / PACS No Images: Radiologist Protocol - Initials Today Next 2 days Next 5 days I.V. Contrast Oral Rectal MEDICAL IMAGING USE ONLY Radiographer: Transport: W/chair Bed Nurse Escort Extras: YES Radiographer’s Initials: Team Leader Signature: MEDICAL IMAGING FINAL CHECK Patient identification verified Procedure & consent verified Correct side & site verified Correct Patient data & side markers Risk Factors for CT, MRI, IVP, Angiography Nil OR >70 years Hx renal impairment Diabetic On Metformin / nephrotoxics If yes to any of the above please complete Blood Requests Creatinine eGFR Test Results - no older than 1 mth / / For Intervention Coag profile required (include INR) Completed No Yes Auslab / QML / S&N / Other Test Results - no older than 1 wk / / Anticoagulants / specify: Previous reaction to contrast? Asthmatic MANDATORY INFORMATION FOR CT, MRI & INTERVENTIONAL PROCEDURES DOWNTIME
Transcript of MEDICAL IMAGING REQUEST Townsville Hospital & Health Service
MEDICAL IMAGING REQUESTTownsville Hospital & Health Service
X-ray - CT - Ultrasound - Nuclear Medicine - MRI - Fluoroscopy - Angiography
The Townsville Hospital - IMB 47100 Angus Smith Drive, Douglas, Qld. 4814Ph: 07 4433 1500Fax: 07 4433 1501 (external use only)
URGENT REQUESTS - Please contact Radiology
Material Number: 10150475 Form Revision: March 2013
DNA Rebook On Hold Cancelled Int: Appt Details:
Clinical History & Provisional Diagnosis:(Include relevant surgery, imaging and pathology results.)
Pregnant? Yes / NoInfectious? Yes / NoAllergies? Yes / No - Specify:
MANDATORY INFORMATION FOR ACCEPTANCE OF THIS REQUEST
UR:
Surname:
Given Name:
DOB: / /
Phone:
Home Address:
RequestedExamination:
Female Ward:Bed No:Clinic:
Consultant / Specialist MOFull Name (Print)
Consent Obtained? Interventional Procedure Renal Impairment General Anaesthetic
Requested by: (Print Full Name)
Declaration: I consider the benefits of the examination justify the risk to the patient.
Signature:
Contact: Ph: Pager:
Billable PatientDr Provider Number:
Date: / /
Date for next clinical review: / /Forward Additional Report to:
Name:
Address:
Male
Room: Acc No:
Scan to QRIS / PACSNo Images:
Radiologist Protocol - Initials
Today Next 2 days Next 5 days
I.V. Contrast Oral Rectal
MEDICAL IMAGING USE ONLY
Radiographer: Transport: W/chair Bed Nurse Escort Extras:
YES
Radiographer’s Initials:
Team Leader Signature:
MEDICAL IMAGING FINAL CHECK
Patient identification verifiedProcedure & consent verifiedCorrect side & site verifiedCorrect Patient data & side markers
Risk Factors for CT, MRI, IVP, Angiography Nil OR >70 years
Hx renal impairment Diabetic On Metformin / nephrotoxics If yes to any of the above please complete Blood Requests
Creatinine eGFR
Test Results - no older than 1 mth / /
For InterventionCoag profile required (include INR)
Completed No Yes Auslab / QML / S&N / Other
Test Results - no older than 1 wk / /
Anticoagulants / specify:
Previous reaction to contrast?Asthmatic
MANDATORY INFORMATION FOR CT, MRI & INTERVENTIONAL PROCEDURES
DOWNTIM
E
CT CHECK LISTRequires Oral Prep No Yes 2 Bottles 3 Bottles Given to Pt By IntRequires Fasting No Yes 4Hrs 6 Hrs
Special Requirements: Such as Pre-Hydration or Steroid cover, please see comments section below.
COMMENTS
DOWNTIM
E
