Ct Patient Screening Form Page 2
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2CT 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(a) 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.
q English
q Spanish
q Other
Tech. Initials _____
Is the patient allergic to any medications, seafood, shellfish, or latex?
Oral Contrast Name ____________
Yes
No
If Yes, please list:
q
q
Amount __________________ mL
1 _______________________ 3
__________________
Lot # ________________________
2 _______________________ 4
__________________
Exp. Date ____________________
Administered By: ______________
List any medication(s) the patient has taken today and all current medications:
(Include birth control and over the counter, ointments, herbals, vitamins, medication patches, etc.)
Title: ________________________
1 _________________________
6
____________________
Barriers to Learning
qYes
qNo
Type:
Intervention:
2 _________________________
7
____________________
q Interpreter Used
q Language
3 _________________________
8
____________________
q Repeat Questions
4 _________________________
9
____________________
q Hearing
q Other ________ q Family/Significant Other
5 _________________________ 10 ____________________
Patient unaware of current medications
Patient not on any medications
q
q
Did patient self-medicate for today’s procedure? q Yes
q No
If yes, do they have a driver?
q Yes
q No
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
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
Dose reduction technique utilized.
q
Yes
q
No If no, why?
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 (a)
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