Understanding Orders, Requests, and Diagnostic Reports

Radiographic Orders

Physician’s request for radiographic examination or radiologic procedure.

Radiology Request

Is a clinical document completed by a licensed physician.

• Stating what procedure or examination is desired.

• This document contains what examination needs to be done,

• Why the examination needs to be conducted, and on

• whom the examination will be performed.

Radiology Request

Stating what procedure or examination is desired.

Radiology Request

This document contains what examination needs to be done.

Radiology Request

why the examination needs to be conducted.

Radiology Request

on whom the examination will be performed.

Physician’s Request

Radiology Request is also known as?

Patient Identification

Right patient for the right procedure.

• Ask the patient

• Check the wrist band or patient’s chart

• Check the following

  • Name of the patient

  • Assigned Identification number (e.g., medical record number)

  • Date of birth

  • Phone number

  • Social security number

  • Address

  • Photo

Ways on how to identify patient:

Patient Identification in the Radiograph

• The patient’s name or patient identification number (PIN).

• Patient’s age or date of birth and gender.

• Date of the study.

• Location where the study was performed.

• Markers are essential to designate right and left.

Patient Identification in the Radiograph

The patient’s name or patient identification number (PIN).

Patient Identification in the Radiograph

Patient’s age or date of birth and gender.

Patient Identification in the Radiograph

Date of the study.

Patient Identification in the Radiograph

Location where the study was performed.

Patient Identification in the Radiograph

Markers are essential to designate right and left.

Verification of Ordered Procedure

Verify with requesting physician.

• Review of Clinical History

• Chief Complaint

• Allergy History

• Localization

• Severity

• Onset

• Aggravating Factors or Alleviating Factors

• Associated Manifestations

• Special Considerations

Clinical History and Patient Assessment:

Role of the Radiographer

• Ensure that correct patient is for the right procedure.

• Perform the correct procedure.

• Provide patient comfort, security, and safety.

• Prepare the examination room and supplies.

Role of the Radiographer

Ensure that correct patient is for the right procedure.

Role of the Radiographer

Perform the correct procedure.

Role of the Radiographer

Provide patient comfort, security, and safety.

Role of the Radiographer

Prepare the examination room and supplies.

Questioning Skills

• Radiologic Technologists must be able to extract vital information from the patient without offending the patient and violating his/her privacy.

• A rapport must be developed to gain the patient’s trust.

Questioning Skills

Radiologic Technologists must be able to extract vital information from the patient without offending the patient and violating his/her privacy.

Questioning Skills

A rapport must be developed to gain the patient’s trust.

Chief Complaint

Medical term used to describe the primary problem of the patient that led the patient to seek medical attention and of the which they are most concerned.

Allergy

An abnormal reaction of the body to a previously encountered allergen, introduced by inhalation, ingestion, injection, or skin contact, often manifested by itchy eyes, runny nose, wheezing, skin rash, or diarrhea.

Pain

Physical suffering or discomfort caused by illness or injury.

Onset

The beginning of pain or complaint.

Aggravating Factors

Factors that make condition worse.

Alleviating Factors

Factors that make condition lessen.

Special Consideration

• For pregnant Patients

• For Pediatric Patients

• For Non-Ambulatory Patients

• For Uncooperative Patients

• For geriatric Patients

• For extremely tall of big Patients

• Other Considerations

Special Consideration

For pregnant Patients

Special Consideration

For Pediatric Patients

Special Consideration

For Non-Ambulatory Patients

Special Consideration

For Uncooperative Patients

Special Consideration

For geriatric Patients

Special Consideration

For extremely tall of big Patients

Other Considerations

Room Preparation

Cleanliness, Organization, and Appearance Necessary supplies and accessory equipment available.

Radiologic Technologists

They must be able to extract vital information from the patient without offending the patient and violating his/her privacy.

Rapport

It must be developed to gain the patient’s trust.