263 lines
5.6 KiB
Markdown
263 lines
5.6 KiB
Markdown
# CT Procedure Log
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| Form ID | FRM-RAD-001 | Revision | 1.0 |
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|---------|-------------|----------|-----|
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---
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## Patient Information
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| Field | Entry |
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|-------|-------|
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| Patient Name | |
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| MRN | |
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| Date of Birth | |
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| Age | |
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| Sex | ☐ Male ☐ Female |
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| Weight | kg / lbs |
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| Height | cm / in |
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## Exam Information
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| Field | Entry |
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|-------|-------|
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| Date of Exam | |
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| Time Start | |
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| Time End | |
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| Ordering Physician | |
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| Exam Type | |
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| Accession Number | |
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| Scanner ID | |
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## Clinical Information
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| Field | Entry |
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|-------|-------|
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| Indication | |
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| Relevant History | |
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| Prior CT exams? | ☐ Yes (Date: _______) ☐ No |
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---
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## Pre-Procedure Screening
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### General Safety
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| Question | Response |
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|----------|----------|
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| Patient identity verified (2 identifiers)? | ☐ Yes |
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| Order verified? | ☐ Yes |
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| Procedure explained to patient? | ☐ Yes |
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| Pregnancy status (if applicable) | ☐ Not pregnant ☐ Pregnant ☐ Unknown ☐ N/A |
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| Metallic implants in scan area? | ☐ Yes (describe: _______) ☐ No |
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### Contrast Screening (if contrast study)
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| Question | Response |
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|----------|----------|
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| Contrast study? | ☐ Yes ☐ No → Skip to Technical Parameters |
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| Previous contrast reaction? | ☐ Yes (describe: _______) ☐ No |
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| Premedication given? | ☐ Yes ☐ No ☐ N/A |
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| Allergies? | ☐ Yes (list: _______) ☐ NKDA |
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| Kidney disease? | ☐ Yes ☐ No |
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| Diabetes? | ☐ Yes ☐ No |
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| Metformin use? | ☐ Yes ☐ No |
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| eGFR/Creatinine | Value: _______ Date: _______ |
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| Adequate renal function? | ☐ Yes ☐ No (radiologist notified) |
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### Consent
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| Field | Entry |
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|-------|-------|
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| Consent obtained? | ☐ Yes ☐ Waived (emergency) |
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| Consent signed by | |
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| Witnessed by | |
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---
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## IV Access (for contrast studies)
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| Field | Entry |
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|-------|-------|
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| IV Access | ☐ Existing ☐ New |
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| Gauge | ☐ 18G ☐ 20G ☐ 22G ☐ Other: |
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| Location | ☐ Right AC ☐ Left AC ☐ Right Hand ☐ Left Hand ☐ Other: |
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| Patency verified | ☐ Yes |
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| Inserted by | |
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## Technical Parameters
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### Protocol Used
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| Field | Entry |
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|-------|-------|
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| Protocol Name | |
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| Body Region | ☐ Head ☐ Neck ☐ Chest ☐ Abdomen ☐ Pelvis ☐ Spine ☐ Extremity ☐ Other |
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| kVp | |
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| mAs (or reference) | |
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| Slice Thickness | mm |
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| Pitch | |
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| Gantry Rotation Time | sec |
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| Scan Mode | ☐ Axial ☐ Helical |
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| Coverage | |
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### Multi-Phase Studies
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| Phase | Delay (sec) | Acquired? |
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|-------|-------------|-----------|
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| Non-contrast | - | ☐ |
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| Arterial | | ☐ |
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| Portal Venous | | ☐ |
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| Delayed | | ☐ |
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| Other: | | ☐ |
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## Contrast Administration
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| Field | Entry |
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|-------|-------|
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| Contrast Agent | |
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| Manufacturer | |
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| Lot Number | |
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| Expiration Date | |
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| Concentration | mgI/mL |
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| Volume Administered | mL |
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| Injection Rate | mL/sec |
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| Injection Method | ☐ Power Injector ☐ Hand Injection |
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| Saline Flush | ☐ Yes Volume: ___mL ☐ No |
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| Warming Used? | ☐ Yes ☐ No |
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### Contrast Timing
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| Field | Entry |
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|-------|-------|
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| Timing Method | ☐ Fixed Delay ☐ Bolus Tracking ☐ Test Bolus |
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| Trigger Location (if tracking) | |
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| Threshold (HU) | |
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| Delay after trigger | sec |
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## Dose Information
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| Metric | Value |
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|--------|-------|
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| CTDIvol | mGy |
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| DLP | mGy·cm |
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| Scan Length | cm |
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| Number of Series | |
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**Dose within reference level?** ☐ Yes ☐ No (explain: _______)
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## Image Quality Assessment
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| Criterion | Satisfactory? |
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|-----------|---------------|
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| Positioning correct | ☐ Yes ☐ No |
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| Coverage adequate | ☐ Yes ☐ No |
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| No significant motion artifact | ☐ Yes ☐ No |
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| Contrast enhancement adequate (if applicable) | ☐ Yes ☐ No ☐ N/A |
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| Noise level acceptable | ☐ Yes ☐ No |
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**Overall Technical Quality:** ☐ Diagnostic ☐ Limited ☐ Non-diagnostic
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**If limited/non-diagnostic, explain:**
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**Repeat acquisition required?** ☐ Yes ☐ No
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## Patient Monitoring (Contrast Studies)
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### During Injection
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| Time | BP | HR | SpO2 | Symptoms |
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|------|----|----|------|----------|
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| Pre-injection | | | | |
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| Post-injection | | | | |
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### Post-Procedure Observation
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| Field | Entry |
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|-------|-------|
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| Observation time | minutes |
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| Any adverse reactions? | ☐ Yes (complete Reaction section) ☐ No |
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| IV site condition at removal | ☐ Normal ☐ Swelling ☐ Erythema ☐ Extravasation |
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## Adverse Reaction (if occurred)
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| Field | Entry |
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|-------|-------|
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| Time of onset | |
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| Type of reaction | ☐ Mild ☐ Moderate ☐ Severe |
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| Symptoms | |
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| Treatment given | |
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| Outcome | ☐ Resolved ☐ Transferred for care |
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| Radiologist notified | ☐ Yes Time: |
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| Adverse Event Report filed | ☐ Yes Report #: |
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## Extravasation (if occurred)
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| Field | Entry |
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|-------|-------|
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| Estimated volume extravasated | mL |
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| Location | |
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| Symptoms | ☐ Pain ☐ Swelling ☐ Erythema ☐ Blistering |
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| Treatment | ☐ Elevation ☐ Ice ☐ Warm compress ☐ Other |
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| Follow-up instructions given | ☐ Yes |
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| Incident report filed | ☐ Yes |
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## Post-Procedure
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| Field | Entry |
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| Patient condition at discharge | ☐ Stable ☐ Other: |
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| Instructions provided | ☐ Hydration ☐ Metformin hold ☐ Reaction warning signs ☐ Other |
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| Images sent to PACS | ☐ Yes |
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| Priority | ☐ Routine ☐ Urgent ☐ STAT |
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## Special Circumstances/Notes
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## Technologist Attestation
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| Field | Entry |
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| Technologist Name | |
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| RT(R)(CT) # | |
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| Signature | |
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| Date | |
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| Time | |
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## Radiologist Review (if applicable at time of exam)
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| Field | Entry |
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| Radiologist Name | |
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| Preliminary Findings | |
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| Signature | |
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*Form FRM-RAD-001 Rev 1.0 - CT Procedure Log*
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