Mri Patient Screening Form - 2016 Page 2

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MRI Patient Screening Form - Part B
Non-Alliance staff accompanying patient received:
Last Name
• MRI Safety training? ............................................
Yes
No
• Verbal safety screening per policy.........................
Yes
No
First Name
Patient’s preferred language for discussing healthcare
Date of Birth
Date
English
Spanish
Other _________________________________
List all current medications including all prescriptions, over the
Iron Deficiency being treated with Feraheme .............
Yes
No
counter items, ointments, vitamins, and herbals. Attach list if
Diabetic? ....................................................................
Yes
No
available.
History of Epilepsy (seizures)? ...................................
Yes
No
Taken
Taken
Chronic Heart Disease (CHF)? ...................................
Yes
No
Today
Today
Currently Breast Feeding? ..........................................
Yes
No
_____________________________
_____________________________
Asthma? .....................................................................
Yes
No
_____________________________
_____________________________
History of Diarrhea in past 2-3 days? .........................
Yes
No
_____________________________
_____________________________
Any Falls within past 30 days? ...................................
Yes
No
_____________________________
_____________________________
If Yes, when ____________________________________________
_____________________________
_____________________________
Allergies to any medications, food or latex? .............. Yes
No
_____________________________
_____________________________
Please List:
Patient unaware of current medications
Patient not on any medications
Yes
No
Did the patient receive an IV injection?
If yes, attachment A054 must be completed and signed
.
Barriers to Learning
Yes
No
Injection site evaluated?
Yes
No
N/A Note appearance:
Type:
Interventions:
Language
Interpreter Used
Post Injection Instructions given
Hearing
Repeat Questions
(applicable to all patients who receive an injection). ..................
Yes
No
N/A
Other
Family/Significant Other
Prior to release, patient was assessed and found impaired?
Yes
No
If yes, supervising physician notified?
Yes
No
If patient refuses further assessment, notify supervising physician and team member to follow policy #5023.
Tech Comments:
RECEIPT OF VERBAL ORDERS, TEST RESULTS, MODIFICATIONS, OR OTHER INSTRUCTIONS
Yes
No
Information Received:
Readback confirmed with
Title
Date
Time
Technologist Signature
Date
Time
Radiologist Signature
Date
Time
Patient notified of rights and opportunity to “Speak Up” with questions or concerns. ...........................................
Yes
No
Handoff Report given to next provider of care. Medication list provided if applicable. ...........................................
Yes
No
N/A
If retail, Patient Rights & Responsibilities provided to the patient. ..........................................................................
Yes
No
N/A
Patient received ear protection. ...............................................................................................................................
Yes
No
Are patient reminder calls for this site made by Team Members? ...........................................................................
Yes
No
EMR
If yes to above and NOT documented in an EMR or Intergy, complete the two rows below.
Team Member Name:
Date:
Time:
Summary of Phone Conversation:
Clinical Pause #2 conducted prior to image transfer
Yes
No
Tech Initials ________
(Correct labeling, annotation and image quality)?
Team Member Signature and Title:
Patient signature below onlY at the comPletion of exam.
I retrieved all of my personal belongings upon completion of exam.
q
I give my consent to receive communication/survey via text or e-mail. q Yes q No q N/A
(Data rates may apply depending on your mobile carrier.)
Preferred Method of Communication: q Cell
q E-mail
Cell #: (
)
E-mail:
I have received a copy of the terms and conditions for electronic communication
q Yes q No q N/A
Patient Signature______________________________________________________________
Revised October, 2016
Attachment A007

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