To go back and review the completed checklist, go to the Imaging tab in Chart Review. I have read and understand the entire content of this form. MRI SAFETY SCREENING QUESTIONNAIRE (OUTPATIENTS) UCLA Form #10956 Rev. At the bottom of the report, you will see the form history of who completed the form. MR Safe clothing will be provided to you to wear during your MRI scan. 0000010863 00000 n Patient Information; Injury Information; Patient Forms; Physical Therapy pt. 0000004593 00000 n 01737 231610. and leave a message, including your full name and contact details. * We recommend checking the boxes off while using this checklist to ensure that an MR Conditional scan with BIOTRONIK ProMRI® systems is permissible. A staff member (typically the MRI technologist or nurse) interviews the patient to ensure preparation instructions were followed and to check for MRI contraindications. h�b``�d``�e`c`9� Ȁ ��@Q� �� �g0�'CV��*��W^W�������r8@L�H����Y8g2�),�s �ZŘ���aA8C&�e�%��s�H_x�xȹ���.��� LؕmT3L��p������ǁl-L �/�p0����;{w�\��#O�X���b`�����1��!vL�1��)��Ļ J%= endstream endobj 350 0 obj <>/Metadata 347 0 R/Pages 346 0 R/StructTreeRoot 10 0 R/Type/Catalog/ViewerPreferences<>>> endobj 351 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/Properties<>/XObject<>>>/Rotate 0/StructParents 0/TrimBox[0.0 0.0 595.276 841.89]/Type/Page>> endobj 352 0 obj <>stream 0000001869 00000 n ���`)���7e'�N��(:Qv��Dى�}~���؉������lp6:���g�����lp6:���g����ؕ�+���y n��0f���.17�r����c6\g�u��7��Ͽ�o�e���P��1n�V4�� �.|�VC?�8g�W� jp � endstream endobj 353 0 obj <> endobj 354 0 obj <>stream H�\��j�0��~ /�EEB��VBHi�JY̏&3@�I�@Y�����# �_[߁K��mwC?��g�}����/�5���̲�]����|m��d 0000001720 00000 n on . Have an MRI chiller installed with all the necessary connections. 0000003097 00000 n MRI SAFETY CHECKLIST cont... 17 Yes / No What is your weight? If yes, when was the most recent? The screening form entitled, Magnetic Resonance (MR) Procedure Screening Form for Patients was created in conjunction with the Medical, Scientific, and Technology Advisory Board and the Corporate Advisory Board of the Institute for Magnetic Resonance Safety, Education, and Research (IMRSER). On this page, you will find instructions for determining if a patient with a Medtronic SureScan™ System meets the criteria to receive an MRI, as well as instructions to follow before, during, and after an MRI scan. INFORMA TION REQUEST & CHECKLIST FOR 425.656.5550 ph 425.656.5552 fax www.vrads.com www.valleymed.org Please FAX back this form and any requested information on the checklist to 425.656.5552. https://www.intersocietal.org/mri/seeking/sample_documents.htm Have you had a previous MRI scan? ��J!��J���1��OGq���^�N��Pvb�. 0000005231 00000 n ¨ Check the MRI Settings status (MRI Settings must be enabled before the scan). Heart Pacemaker or Defibrillator Yes No *Aneurysm […] 0000082952 00000 n If you are unable to remove any of the above items please notify the technologist. 0000050389 00000 n 0000042057 00000 n MRI Safety Checklist. (Stones) (Kilograms) 18 19 Could you be pregnant? IAC MRI Accreditation Checklist (Updated 11-2-2020) Page | 4 : Case Study Requirements : Applicant facilities must submit six case studies for each MRI scanner for review of the interpretive and technical (clinical image) quality. Emory Low Dose CT Lung Screening Order Form: CT: All Emory Healthcare locations: Download PDF (68KB) CT Lung Screening: Shared Decision Making Checklist for Providers: CT: All Emory Healthcare locations: Download PDF (103KB) Emory Breast Imaging Order Form (For all BIC Locations) Mammography, Breast MRI, Breast Ultrasound, Breast Biopsy IMAGEREADY™ MRI CHECKLIST FOR VERCISE™ DIRECTIONAL* DBS SYSTEMS This form provides information about the patient’s implanted DBS system MRI scan eligibility. MRI SCANNING CHECKLIST PATIENT PRE-SCREENING SureScan™ Pacing and Defibrillation Systems Verification § Verify that patient has a complete SureScan Pacing or Defibrillation System, which consists of an approved combination MRI SureScan device with SureScan 0000091978 00000 n 0000035833 00000 n 4. • Find the study you are looking for, single click to open the Final Report. 0000079023 00000 n 0000027761 00000 n 0000006105 00000 n It may be provided to the radiologist to support the confirmation of the patient’s MRI scan eligibility. Patient Prep Checklist Upon arrival, the patient completes all necessary paperwork including the MRI screening form and any relevant consent forms. 0000042404 00000 n 0000050428 00000 n Follow our simple actions to have your Mri Checklist Form well prepared rapidly: Find the template from the catalogue. 20 Are you breast-feeding? Your program can use any format to keep records of your progress. Your ARRT application form must include the endorsing signatures of your Program Director and, if applicable, other authorized faculty members. Compliance Checklist: Diagnostic Imaging Use this checklist to help evaluate your compliance with The Joint Commission’s diagnostic imaging requirements. If you do receive medication, please bring someone with you that will be able to drive you home because you will not be able to drive yourself.Relax and do not worry about the exam! 0000004977 00000 n 3. Magnetic Resonance Imaging mri. 0000031182 00000 n For questions, call 425.656.5550. 0000003668 00000 n 0000056816 00000 n Patient must be continuously monitored during the MRI scan by pulse oximetry and/or electrocardiography. H�\��n�0��~ The specific procedures for the Technologist Quality Control Program are those specified in the most current ACR MRI QC Manual. MRI APPROPRIATENESS CHECKLIST Fax Outpatient Checklist to MRI Central Intake: 1-866-588-6955 IMPORTANT: The following information is required in order for us to process your request. 10. Enter all required information in the required fillable fields. When you make an appointment for an MRI examination, you will be asked a series of safety questions to ensure you do not have any implanted devices that may prevent you from undergoing the procedure. ��K��5m==��k}��$���������'e����m�e������&�mwq/���W����'\C7��[�\�q�/������M|�N��8�߈��!�|~�(S�M� Uƪ���\�c�ʏx���5��7�ӹ�]�I�}����j�s�������d��l�7�[�-�y��g�#�oIYp��s��3��s�,̂�=�2+�12�8t.�\���1���+� Date Last Revised:3/18/2019 Page 1 How to view MRI Screening Form in EPIC Staff can now see the MRI Screening Form in EPIC • Open the patient’s chart to Chart Review. 0000008354 00000 n This is being done to help ensure your safety during the examination. Please ensure all loose metallic objects, including metallic body piercing, hearing aids, foil drug patches and dentures are removed prior to the scan. 0000005382 00000 n 0000016461 00000 n About; MRI Checklist; MRI Forms; Patient Resources pr. The intuitive drag&drop graphical user interface makes it simple to add or relocate areas. 0000006694 00000 n Technologist Quality Control Procedures . �Cq�C�!F� �v�����̰�Fqy�*n�`����o�s�^�O��8�t��&�-���� �۴v����J��c¡�.��}qL�J�C������lA7S��8 %(���a'�.&^̀�3����>�;a��9"r������E6ԣ*� 0000004677 00000 n MRI Scan Patient Checklist: ... For additional instructions, refer to the St. Jude Medical MRI Procedure information document, the Ellipse ICD, Fortify Assura ICD, Durata lead and Optisure lead manuals. If you would like to fill out an MRI Safety Checklist prior to your MRI, please complete the online MRI Safety Checklist form. 0000028034 00000 n ¨ Perform the scan and monitor the patient. Checklist before MRI scanning This checklist will help to ensure the safe application of an MR scan on patients with a BIOTRONIK device system that has been labeled MR Conditional. Contact the Standards Interpretation Group at (630) 791-5900 for assistance. YES NO 2. 0000012806 00000 n 0000004177 00000 n H�\�͊�@��>E-��Qo�� �!��a2� F+a�b�"o?uFP�XU��A+�v���\�}��c�ܹ�1���Xw Do you have a Cardiac Pacemaker/defibrillator or had heart surgery? ¨ Disable the pulse generator MRI Settings. About; MRI Checklist; MRI Forms; Patient Resources pr. That form states that you’ve demonstrated competence in specific procedures at a specific time. NOTE Ensure that external defibrillator and medical personnel skilled in CPR are present during the MRI scan should the patient require external rescue. 0000038519 00000 n 349 0 obj <> endobj xref 349 56 0000000016 00000 n ���+� Failure to disclose information could result in serious injury. 0000021596 00000 n £IB2Ü.SƱ }u òÊÍ)Ó›“‹n…ü$‡äà ›ïs»ÙÎ)ıâˆ!ƒ­ÁaσŞMú0#‚,Ø®qÜ÷yÙ1óçøZBUôşÆF‡S2É„E­¸4Ôo\Z`pÿúÕ�êzûc¨¸_Ø­T¥ôª�‡¢NÇÂ>\ë^�íLÄéÊEJ¬5�ø. 0000024335 00000 n Patient Checklist for MRI Please arrive 15 minutes before your exam time. 0000109337 00000 n • Scroll down in the report until you see Screening Form Questions. 1. The chiller may be provided as part of the deal, or you may need to purchase one yourself. 0000008211 00000 n 0000018228 00000 n 0000020012 00000 n MRI UNIT. Signature of patient: Date: 0000040015 00000 n 0000085651 00000 n 0000014634 00000 n • Select the Imaging Tab. ABOUT ARRT AND YOUR EDUCATIONAL PROGRAM. 1 As defined in IEC 60601 -2 33, 201.3.244, 3rd Edition. One or more criteria must apply for the referred examination type for the MRI exam to proceed. 6. 0000008740 00000 n In: Kanal E, Barkovich A, Bell C, et al. 0000010391 00000 n I confirm that I have answered all the questions and the information is correct to the best of my knowledge. Knee MRI Checklist (sequence based) Sagital FSE PD: Cruciate ligaments Anterior Cruciate Ligament (pd fat sat) Pitfalls: -Partial volume averaging with lat fem condyle -ACL myxoid degeneration/cyst … Select the MRI order, the details of the MRI will show in the preview portion of the screen (including the details of the completed screening form). ���+� Do not take the Merlin Programming system into the MRI room (Zone IV) or past the 5 Gauss line. Do you have aneurysm clips in your brain? 0000038482 00000 n trailer <<6285A242FA4E45CA920E5F2C6263ECA0>]/Prev 159956>> startxref 0 %%EOF 404 0 obj <>stream Patient Information; Injury Information; Patient Forms; Physical Therapy pt. 0000040362 00000 n 0000002456 00000 n 0000006552 00000 n 0000042809 00000 n YES NO 3. Pre MRI Exam Checklist If you think you may be claustrophobic, ask your doctor to prescribe medication prior to the exam. I confirm that that the information I have provided is correct to the best of my knowledge. ]��]�x� ��T�-~��eN7����C|4ŏ���'��g����:M����.l]�.u�o���9G[�eO�N�����k�U��Mі�~I�v��ejژ��M�У�ջ��C�߼�\v8�M2��]�=_jS��|���3��B�5��F~s/L�Zf�AyM^+;>wx�Jr ^�W`Gv`!�>>�>>�����+�LOO�%o��t��������������������G�E�EX/���œ=X����\�\�\�[��B���޹ܿ�f ��% K�[�[�[�[�[�[�C�C��h�{������W��ה�E�o�{]���ϙ���*�� ���� endstream endobj 355 0 obj <> endobj 356 0 obj <> endobj 357 0 obj <>stream ���+� %PDF-1.4 %���� clothing and worn/removable items from your body. Checklist with their referring provider or on their own as soon as possible. 0000005345 00000 n 0000005004 00000 n If the answer to any of the questions on the MRI Safety Checklist is YES, please call 919 … 0000001416 00000 n Appendix 3: safety screening form, MR hazard checklist, and patient instructions. 0000028207 00000 n Am J Roentgenol 2007 Jun;188(6):1447-74. Need help? Bold fi elds must be completed to avoid delays in patients processing. 0000054227 00000 n Please provide a … 0000024265 00000 n ACR guidance document for safe MR practices: 2007. (04/12) Page 1 of 2 MRN: Patient Name: (Patient Label) Sex: Age: Height: Weight: The following items may be harmful to you during your MR scan or may interfere with the MR examination. 0000024419 00000 n Select the Correct Scan Parameters for your MRI equipment. ���+3�� z�&�M؛�7ao�ބ� z��ͣ7OggOggOggOggOggOggOggOOOe?�~�,K�R��,K�R�T��2Y 0000039697 00000 n Note: If you are not using the SJM MRI Activator™ handheld device, the MRI Settings must be disabled by the Qualified Medical Physicist/MRI Scientist Date: Patient Transport and Gantry Filming Viewing: MRI Accreditation Program Visual Checklist RF Integrity and Control Room Facility Safety Technologist Initials: Date of Review: Pass = Fail =F MRI patient Checklist & Consent Name Date of Birth MM DD YYYY MRN HT WT Tech Indications The following may be hazardous or may interfere with the examination by producing an artifact Please remove all jewlery (except wedding band), bobby pins, watches, cell phone, credit cards, hearing aids. 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