image guided interventional procedures request · title: image guided interventional procedures...
TRANSCRIPT
Department Use Only Date format: yyyy-Mon-dd - Time format: hh:mmDate Received Time Received Appointment Date Appointment Time
More info required o No o Yes (specify): Day Med booked o No o Yes
Image Guided Interventional
Procedures Request
Current Patient Condition
Radiologist to Complete o CT o IR Suite o US
Priority
o 24 hr
o 1 week
o Next Available
o Other (specify):
o Day Med
o DIRR
o OP Radiology
o GA
o PAC
o Inpatient
Bloodwork o None
o Electrolytes o LFT’s
o Creatinine o CBC
o Bilirubin o PT/INR
o Other (specify):
Required within
o 1 week o 4 weeks
09015(Rev2017-05)
< Fax to Diagnostic Imaging; fax numbers listed athttp://www.albertahealthservices.ca/diagnosticimaging
< Urgent/Emergent requests must bediscussed by direct consultation withthe radiologist
Preferred Facility
Exam requested (indicate specimen required for biopsies/drainages)
Relevant clinical history/presumptive diagnosis
Clinical question to be answered
Patient label here or information below is required
Last Name First Name
Birthdate (yyyy-Mon-dd) Gender
Address (street, city, province, postal code)
PHN Daytime Phone
Inpatient location
Date of LMP (yyyy-Mon-dd) Height o cm o in Weight o kg o lbs
For biopsies and drainages, indicate specific lab or specimen required: (attach orders)o Creatinine o Glucose o LDH o Albumin o Bilirubin o Gram Stain o AFB o Fungi o Culture & Sensitivity (specify antibiotic use): o pH o Cytology o Cell Count o Other (specify):
Condition No Yes If Yes:
Allergies (include any reaction to contrast media) o o Specify:
On Anticoagulants o o Specify:
Medications (including ASA, Plavix) o o Specify:
Isolation Precautions o o Specify type:
Diabetic o o Metformin (Glucophage) o No o Yes
Renal Insufficiency o oOn Dialysis o o Run days:
Mechanical lift/transfer required o o
Relevant Previous Imaging Studies
Location Type Date (yyyy-Mon-dd) Attached copy
o No o Yes
Pre-Care
o Pre-Op required
o Admit day of exam;
prep required
o Admit day of exam and GA;
prep required
Admit ____ hrs prior
Admit ____ hrs prior
Admit ____ hrs prior
Length of Recovery
o N/A o 2 hrs o 4 hrs o ___ hrs
Procedural Protocol
Patient position o supine o prone
Referring Physician (PRINT first and last name) Physician Phone(required)
Physician Fax(required)
Contact Number for CriticalTest Results (required)
Signature Date (yyyy-Mon-dd) Copy to Physician (first and last) Copy to Fax