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 #: |
| 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 |
Special Circumstances/Notes
Technologist Attestation
| Field |
Entry |
| Technologist Name |
|
| RT(R)(CT) # |
|
| Signature |
|
| Date |
|
| Time |
|
Radiologist Review (if applicable at time of exam)
| Field |
Entry |
| Radiologist Name |
|
| Preliminary Findings |
|
| Signature |
|
Form FRM-RAD-001 Rev 1.0 - CT Procedure Log
