Mri Patient Screening Form Page 2
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2MRI Patient Screening Form - Part B
Patient Label or Accession Number
Patient Name (Last, First):
Date of Birth:
Date:
Did the patient receive an IV injection?
Yes
No
If yes, attachment A054 must be completed and signed.
q
q
Patient’s preferred language for discussing healthcare:
Clinical pauses conducted prior to exam AND prior
to image transfer.
Tech Initials ____
q English
q Spanish
q Other
Is the patient allergic to any medications, seafood, shellfish, or latex?
Yes
No
If Yes, please list:
Barriers to Learning
q Yes
q No
q
q
Type:
Intervention:
1 _______________________ 4
__________________
q Language
q Interpreter Used
2 _______________________ 5
__________________
q Hearing
q Repeat Questions
q Other _______________ q Family/Significant Other
3 _______________________ 6
__________________
List any medication(s) the patient has taken today and all current medications:
(Include birth control and over the counter, ointments, herbals, vitamins, etc.)
1 _______________________ 6
__________________
Did the patient self-medicate for today’s procedure?
2 _______________________ 7
__________________
o Yes
o No
3 _______________________ 8
__________________
If yes, do they have a driver? o Yes
o No
4 _______________________ 9
__________________
5 _______________________ 10 __________________
Patient unaware of current medications
Patient not on any medications
q
q
Prior to release, patient was assessed and found impaired? q Yes q No If yes, supervising physician notified? q Yes q No
If patient refuses further assessment, notify supervising physician and Alliance personnel to follow policy #5023.
Injection site evaluated?
q Yes
q No
q N/A Note appearance:
Comments:
RECEIPT OF VERBAL ORDERS, TEST RESULTS, MODIFICATIONS, OR OTHER INSTRUCTIONS
q Yes q No
Information Received: ________________________________________________________________________________________________
Readback confirmed with _________________________________ Title ______________________ Date ______________ Time ___________
Technologist or Radiologist Signature: _________________________________________________ Date ______________ Time ___________
Post Injection Instructions given (applicable to all patients who receive an injection).
q Yes
q No
q N/A
Patient notified of rights and opportunity to “Speak up” with questions or concerns.
q Yes
q No
Handoff Report given to next provider of care. Medication list provided if applicable.
q Yes
q No
q N/A
If retail, Patient Rights & Responsibilities provided to the patient.
q Yes
q No
q N/A
Patient received ear protection.
q Yes
q No
Are patient reminder calls for this site made by Alliance Team Members?
q Yes
q No
q EMR
If yes to above and NOT documented in an EMR or Intergy, complete row below.
Team Member Name: ________________________________________________________Date: _____________ Time: __________
Summary:
Technologist Comments:
Team Member Signature and Title:
PatIent sIgnature below onlY at the comPletIon oF exam.
I did not leave any personal belongings upon completion of exam.
Revised January 1, 2014
Attachment A007
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