Mri Patient Screening Form Page 2
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2MRI Patient Screening Form -
Part B
Patient Label
Pt Name (Last, First):
Date of Birth:
Date:
CONTRAST
Your physician or radiologist may deem it necessary for you to have an IV injection of a contrast agent containing
gadolinium to improve the quality of your MR examination. Although gadolinium contrast agents have been used
safely in millions of patients, minor reactions (principally headache or nausea), and serious or life threatening
reactions may occur.
I have read and understand the above information, and have had my questions
Contrast Name _______________
answered. I agree to have the MRI procedure with injection of contrast if
Amount _____________________
deemed necessary.
Have you ever had an injection of contrast before?
Yes
No
Lot # ________________________
q
q
History of previous reaction
Yes
No
q
q
Exp. Date ____________________
If Yes, Explain ______________________________________________________
Injection Site _________________
Patient Stated Weight ______________
Device Used _________________
eGFR ______________ (If under 60, consult radiologist. Document all protocol
Rate of Admin. ________________
changes in Modification Section below.)
Tech Initials __________________
__________________________________________ Date: ___________________
Signature of Patient (Parent or Guardian if patient is a Minor or Incapacitated)
Post Injection Check:
Time:___________ Has patient’s condition changed since injection? No _____ Yes _____
If Yes, specify change: _____________________________________________________________________________
Are you allergic to any medications, seafood, shellfish, or latex?
Barriers to Learning
q Yes
q No
Yes
No
If Yes, please list:
Type:
Intervention:
q
q
1 _______________________ 4
__________________
q Interpreter Used
q Language
2 _______________________ 5
__________________
q Repeat Questions
q Hearing
3 _______________________ 6
__________________
q Family/Significant Other
q Other
Patient unaware of current medications
Patient not on any medications
q
q
List any medication(s) the patient has taken today and all current medications:
(Include birth control and over the counter, ointments, herbals, vitamins, etc.)
If patient has self-medicated for anxiety/claustrophobia
1 _______________________ 5
__________________
specifically for today’s procedure (not routine
2 _______________________ 6
__________________
medications), do they have a driver?
3 _______________________ 7
__________________
o No
o N/A - Patient did not pre-medicate
o Yes
4 _______________________ 8
__________________
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.
Comments: __________________________________________________________________________________________________
RECEIPT OF VERBAL ORDERS, TEST RESULTS, MODIFICATIONS, OR OTHER INSTRUCTIONS
q Yes q No
Information Received: ________________________________________________________________________________________
Readback confirmed with ________________________ Title ______________________ Date ______________ Time ___________
Technologist Signature: ____________________________________________________________________ Date ______________
q
q
q
Post Injection Instructions given (applicable to all patients who receive an injection).
Yes
No
N/A
q
q
Patient notified of rights and opportunity to “Speak up” with questions or concerns.
Yes
No
q
q
q
Handoff Report given to next provider of care. Medication list provided if applicable.
Yes
No
N/A
q
q
q
If retail, Patient Rights & Responsibilities provided to the patient.
Yes
No
N/A
q
q
q
Are patient reminder calls for this site made by Alliance TMs?
Yes
No
EMR
If yes to above and NOT documented in an EMR or Intergy, complete row below.
TM Name: __________________ Date: _______ Time: _______ Summary: _____________________________________
Team Member Signature: ______________________________________ _______________________________________
Title: ____________________________________________________________________________ Date: ______________
Technologist Comments _____________________________________________________________________________
Revised January 1, 2012
Attachment A007
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