General Radiology Orders - Children`s Hospital of The King`s

CHILDREN’S HOSPITAL OF THE KING’S DAUGHTERS, INC.

601 Children’s Lane, Norfolk, VA 23507-1910

Radiology Department GENERAL RADIOLOGY STUDY ORDERS AND DOWNTIME FORM Wt :________ kg

Ht :________ cm

Patient Label or MRN, Acct#, Patient Name, DOB, Date of Service

Allergies:

NKA or ___________________________________________

Pregnancy Status per lab request:

Positive

Negative

N/A (Male, Premenarche, Distal film (elbow or knee)

Precautions/Isolation:

Droplet

Airborne

N/A

Contact

Call Critical Results or Questions to: *Please provide a phone number or pager number that can be reached at the time of the examination and/or reading

Information you wish to gain from this study:

Pertinent Clinical/Surgical History and Physical Exam Findings:

Date needed: _________________

Exam Requested 1:

Routine

Urgent

Stat

Portable film (PICU, NICU, pt is unstable)

If needed: indicate contrast type below With IV contrast

Date needed: _________________ (must be for same indication as above or use a separate order form) Exam Requested 2:

Routine

Urgent

Stat

With and Without IV contrast With PO contrast

Portable film (PICU, NICU, pt is unstable)

If needed: indicate contrast type below With IV contrast

If IV contrast is ordered indicate type of Line access: Yes

Floor/Unit TO ACCESS:

If needed:

No

OR

Needs IV

PIV

Sedation RN TO ACCESS:

CVL

Physician Signature

STUDY CT head WITHOUT contrast

CT abd/pelvis W/OUT contrast CT abd/pelvis WITH contrast CT orbits WITHOUT contrast CT orbits WITH contrast CT facial bones CT mandible CT temporal bones w/o contrast CT temporal bones w/ contrast

Port

Yes (Must fax Flush orders)

Sedation (Available M-F 7a-3:30p call 668-7680 to schedule) or

Date and Time

With and Without IV contrast With PO contrast

No

Anesthesia (Contact 668-7320 for availability)

Print Physician Name

GUIDELINES TO ORDERING THE APPROPRIATE RADIOLOGIC STUDY Indication(s) STUDY

PIC(Simon)/Pager #:

Indication(s)

Trauma (skull fracture, intracranial hemorrhage), Hydrocephalus (VP shunt malfunction) Renal stones

Chest L\R lateral decubitus

Lower airway foreign body, pleural effusions

Abdomen 1 view

Appendicitis, intra-abdominal abscess, intraabdominal pelvic tumor Trauma – Orbital fracture, globe injury Infection such as (peri)orbital cellulitis, tumor Fracture of facial bones (includes orbits, midface, and mandible) Fracture mandible Basilar skull fracture

Bone survey

Constipation/gallstone/fecalith/renal stone Suspected non-accidental trauma in children less than 2 years old Shoulder dislocation Patellar Fracture/dislocation Usually ordered in conjunction with CT Head WITHOUT contrast Requires Foley catheter in place. Dental disease. Requires transport to SNGH. Order in consultation w/ dentist or OMFS.

Scapula Y view Knee, Sunrise view Shunt series Pelvic US (trans-abdominal) Panorex

Mastoiditis

Amer Coll of Radiology Diagnosis Guidelines: http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx CHKD Form 2421 MR Rev 1/11