# CT Procedure Log

| Form ID | FRM-RAD-001 | Revision | 1.0 |
|---------|-------------|----------|-----|

---

## Patient Information

| Field | Entry |
|-------|-------|
| Patient Name | |
| MRN | |
| Date of Birth | |
| Age | |
| Sex | ☐ Male ☐ Female |
| Weight | kg / lbs |
| Height | cm / in |

---

## Exam Information

| Field | Entry |
|-------|-------|
| Date of Exam | |
| Time Start | |
| Time End | |
| Ordering Physician | |
| Exam Type | |
| Accession Number | |
| Scanner ID | |

---

## Clinical Information

| Field | Entry |
|-------|-------|
| Indication | |
| Relevant History | |
| Prior CT exams? | ☐ Yes (Date: _______) ☐ No |

---

## Pre-Procedure Screening

### General Safety

| Question | Response |
|----------|----------|
| Patient identity verified (2 identifiers)? | ☐ Yes |
| Order verified? | ☐ Yes |
| Procedure explained to patient? | ☐ Yes |
| Pregnancy status (if applicable) | ☐ Not pregnant ☐ Pregnant ☐ Unknown ☐ N/A |
| Metallic implants in scan area? | ☐ Yes (describe: _______) ☐ No |

### Contrast Screening (if contrast study)

| Question | Response |
|----------|----------|
| Contrast study? | ☐ Yes ☐ No → Skip to Technical Parameters |
| Previous contrast reaction? | ☐ Yes (describe: _______) ☐ No |
| Premedication given? | ☐ Yes ☐ No ☐ N/A |
| Allergies? | ☐ Yes (list: _______) ☐ NKDA |
| Kidney disease? | ☐ Yes ☐ No |
| Diabetes? | ☐ Yes ☐ No |
| Metformin use? | ☐ Yes ☐ No |
| eGFR/Creatinine | Value: _______ Date: _______ |
| Adequate renal function? | ☐ Yes ☐ No (radiologist notified) |

### Consent

| Field | Entry |
|-------|-------|
| Consent obtained? | ☐ Yes ☐ Waived (emergency) |
| Consent signed by | |
| Witnessed by | |

---

## IV Access (for contrast studies)

| Field | Entry |
|-------|-------|
| IV Access | ☐ Existing ☐ New |
| Gauge | ☐ 18G ☐ 20G ☐ 22G ☐ Other: |
| Location | ☐ Right AC ☐ Left AC ☐ Right Hand ☐ Left Hand ☐ Other: |
| Patency verified | ☐ Yes |
| Inserted by | |

---

## Technical Parameters

### Protocol Used

| Field | Entry |
|-------|-------|
| Protocol Name | |
| Body Region | ☐ Head ☐ Neck ☐ Chest ☐ Abdomen ☐ Pelvis ☐ Spine ☐ Extremity ☐ Other |
| kVp | |
| mAs (or reference) | |
| Slice Thickness | mm |
| Pitch | |
| Gantry Rotation Time | sec |
| Scan Mode | ☐ Axial ☐ Helical |
| Coverage | |

### Multi-Phase Studies

| Phase | Delay (sec) | Acquired? |
|-------|-------------|-----------|
| Non-contrast | - | ☐ |
| Arterial | | ☐ |
| Portal Venous | | ☐ |
| Delayed | | ☐ |
| Other: | | ☐ |

---

## Contrast Administration

| Field | Entry |
|-------|-------|
| Contrast Agent | |
| Manufacturer | |
| Lot Number | |
| Expiration Date | |
| Concentration | mgI/mL |
| Volume Administered | mL |
| Injection Rate | mL/sec |
| Injection Method | ☐ Power Injector ☐ Hand Injection |
| Saline Flush | ☐ Yes Volume: ___mL ☐ No |
| Warming Used? | ☐ Yes ☐ No |

### Contrast Timing

| Field | Entry |
|-------|-------|
| Timing Method | ☐ Fixed Delay ☐ Bolus Tracking ☐ Test Bolus |
| Trigger Location (if tracking) | |
| Threshold (HU) | |
| Delay after trigger | sec |

---

## Dose Information

| Metric | Value |
|--------|-------|
| CTDIvol | mGy |
| DLP | mGy·cm |
| Scan Length | cm |
| Number of Series | |

**Dose within reference level?** ☐ Yes ☐ No (explain: _______)

---

## Image Quality Assessment

| Criterion | Satisfactory? |
|-----------|---------------|
| Positioning correct | ☐ Yes ☐ No |
| Coverage adequate | ☐ Yes ☐ No |
| No significant motion artifact | ☐ Yes ☐ No |
| Contrast enhancement adequate (if applicable) | ☐ Yes ☐ No ☐ N/A |
| Noise level acceptable | ☐ Yes ☐ No |

**Overall Technical Quality:** ☐ Diagnostic ☐ Limited ☐ Non-diagnostic

**If limited/non-diagnostic, explain:**

**Repeat acquisition required?** ☐ Yes ☐ No

---

## Patient Monitoring (Contrast Studies)

### During Injection

| Time | BP | HR | SpO2 | Symptoms |
|------|----|----|------|----------|
| Pre-injection | | | | |
| Post-injection | | | | |

### Post-Procedure Observation

| Field | Entry |
|-------|-------|
| Observation time | minutes |
| Any adverse reactions? | ☐ Yes (complete Reaction section) ☐ No |
| IV site condition at removal | ☐ Normal ☐ Swelling ☐ Erythema ☐ Extravasation |

---

## Adverse Reaction (if occurred)

| Field | Entry |
|-------|-------|
| Time of onset | |
| Type of reaction | ☐ Mild ☐ Moderate ☐ Severe |
| Symptoms | |
| Treatment given | |
| Outcome | ☐ Resolved ☐ Transferred for care |
| Radiologist notified | ☐ Yes Time: |
| Adverse Event Report filed | ☐ Yes Report #: |

---

## Extravasation (if occurred)

| Field | Entry |
|-------|-------|
| Estimated volume extravasated | mL |
| Location | |
| Symptoms | ☐ Pain ☐ Swelling ☐ Erythema ☐ Blistering |
| Treatment | ☐ Elevation ☐ Ice ☐ Warm compress ☐ Other |
| Follow-up instructions given | ☐ Yes |
| Incident report filed | ☐ Yes |

---

## Post-Procedure

| Field | Entry |
|-------|-------|
| Patient condition at discharge | ☐ Stable ☐ Other: |
| Instructions provided | ☐ Hydration ☐ Metformin hold ☐ Reaction warning signs ☐ Other |
| Images sent to PACS | ☐ Yes |
| Priority | ☐ Routine ☐ Urgent ☐ STAT |

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## Special Circumstances/Notes

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## Technologist Attestation

| Field | Entry |
|-------|-------|
| Technologist Name | |
| RT(R)(CT) # | |
| Signature | |
| Date | |
| Time | |

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## Radiologist Review (if applicable at time of exam)

| Field | Entry |
|-------|-------|
| Radiologist Name | |
| Preliminary Findings | |
| Signature | |

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*Form FRM-RAD-001 Rev 1.0 - CT Procedure Log*