0000018228 00000 n 0000006694 00000 n I confirm that that the information I have provided is correct to the best of my knowledge. 0000056816 00000 n 0000020012 00000 n 0000040362 00000 n 0000010863 00000 n YES NO 2. ]��]�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 If yes, when was the most recent? 3. 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. Have you had a previous MRI scan? Pre MRI Exam Checklist If you think you may be claustrophobic, ask your doctor to prescribe medication prior to the exam. 0000008211 00000 n 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). 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. 6. 0000024265 00000 n Please ensure all loose metallic objects, including metallic body piercing, hearing aids, foil drug patches and dentures are removed prior to the scan. 0000085651 00000 n 0000079023 00000 n At the bottom of the report, you will see the form history of who completed the form. For questions, call 425.656.5550. 0000035833 00000 n 0000109337 00000 n 0000005004 00000 n Magnetic Resonance Imaging mri. 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. ���+3�� z�&�M؛�7ao�ބ� z��ͣ7OggOggOggOggOggOggOggOOOe?�~�,K�R��,K�R�T��2Y ��J!��J���1��OGq���^�N��Pvb�. 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 0000005382 00000 n 10. ¨ Disable the pulse generator MRI Settings. Failure to disclose information could result in serious injury. /�EEB��VBHi�JY̏&3@�I�@Y�����# �_[߁K��mwC?��g�}����/�5���̲�]����|m��d 4. • Scroll down in the report until you see Screening Form Questions. %PDF-1.4 %���� Enter all required information in the required fillable fields. Do you have aneurysm clips in your brain? ���`)���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 Follow our simple actions to have your Mri Checklist Form well prepared rapidly: Find the template from the catalogue. 0000005231 00000 n About; MRI Checklist; MRI Forms; Patient Resources pr. Bold fi elds must be completed to avoid delays in patients processing. 20 Are you breast-feeding? 0000050428 00000 n 0000004677 00000 n The patient scanning process refers to the steps that must be followed to help ensure patient safety during an MRI scan. Note: If you are not using the SJM MRI Activator™ handheld device, the MRI Settings must be disabled by the 01737 231610. and leave a message, including your full name and contact details. ¨ Perform the scan and monitor the patient. 0000012806 00000 n Magnetic Resonance Imaging mri. Select the Correct Scan Parameters for your MRI equipment. 1 As defined in IEC 60601 -2 33, 201.3.244, 3rd Edition. MRI Safety Checklist. 0000005116 00000 n H�\��n�0��~ To go back and review the completed checklist, go to the Imaging tab in Chart Review. 0000002456 00000 n 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. ¨ Check the MRI Settings status (MRI Settings must be enabled before the scan). Your MRI will take about 45 minutes, so plan on being at the MRI imaging center for around one hour. clothing and worn/removable items from your body. 0000010391 00000 n 0000008740 00000 n Patient Checklist for MRI Please arrive 15 minutes before your exam time. �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*� Patient Information; Injury Information; Patient Forms; Physical Therapy pt. 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 ��K��5m==��k}��$���������'e����m�e������&�mwq/���W����'\C7��[�\�q�/������M|�N��8�߈��!�|~�(S�M� Uƪ���\�c�ʏx���5��7�ӹ�]�I�}����j�s�������d��l�7�[�-�y��g�#�oIYp��s��3��s�,̂�=�2+�12�8t.�\���1���+� 0000014634 00000 n Technologist Quality Control Procedures . 0000001720 00000 n 0000028034 00000 n 0000031182 00000 n ���+� Heart Pacemaker or Defibrillator Yes No *Aneurysm […] MRI SAFETY SCREENING QUESTIONNAIRE (OUTPATIENTS) UCLA Form #10956 Rev. Please provide a … This is being done to help ensure your safety during the examination. It may be provided to the radiologist to support the confirmation of the patient’s MRI scan eligibility. INFORMA TION REQUEST & CHECKLIST FOR 425.656.5550 ph 425.656.5552 fax www.vrads.com www.valleymed.org Please FAX back this form and any requested information on the checklist to 425.656.5552. Knee MRI Checklist (sequence based) Sagital FSE PD: Cruciate ligaments Anterior Cruciate Ligament (pd fat sat) Pitfalls: -Partial volume averaging with lat fem condyle -ACL myxoid degeneration/cyst … 0000006105 00000 n 1. H�\��j�0��~ Your ARRT application form must include the endorsing signatures of your Program Director and, if applicable, other authorized faculty members. This will give you time to fill out your patient registration and final MRI screening forms and then dress for your MRI. £IB2Ü.SƱ }u òÊÍ)Ó›“‹n…ü$‡äà ›ïs»ÙÎ)ıâˆ!ƒ­ÁaσŞMú0#‚,Ø®qÜ÷yÙ1óçøZBUôşÆF‡S2É„E­¸4Ôo\Z`pÿúÕ�êzûc¨¸_Ø­T¥ôª�‡¢NÇÂ>\ë^�íLÄéÊEJ¬5�ø. 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. That form states that you’ve demonstrated competence in specific procedures at a specific time. Appendix 3: safety screening form, MR hazard checklist, and patient instructions. Patient must be continuously monitored during the MRI scan by pulse oximetry and/or electrocardiography. 0000003097 00000 n If you are unable to remove any of the above items please notify the technologist. 0000024335 00000 n 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 0000005345 00000 n Do not take the Merlin Programming system into the MRI room (Zone IV) or past the 5 Gauss line. If the answer to any of the questions on the MRI Safety Checklist is YES, please call 919 … YES NO 3. 0000004977 00000 n (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. Patient Prep Checklist Upon arrival, the patient completes all necessary paperwork including the MRI screening form and any relevant consent forms. 2. I have read and understand the entire content of this form. The intuitive drag&drop graphical user interface makes it simple to add or relocate areas. Contact the Standards Interpretation Group at (630) 791-5900 for assistance. 0000008354 00000 n 0000082952 00000 n The chiller may be provided as part of the deal, or you may need to purchase one yourself. 0000038519 00000 n 0000042404 00000 n 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. MRI UNIT. I confirm that I have answered all the questions and the information is correct to the best of my knowledge. ACR guidance document for safe MR practices: 2007. ���+� 0000004177 00000 n (Stones) (Kilograms) 18 19 Could you be pregnant? 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. 0000040015 00000 n If you would like to fill out an MRI Safety Checklist prior to your MRI, please complete the online MRI Safety Checklist form. 0000042809 00000 n 0000028207 00000 n 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). 349 0 obj <> endobj xref 349 56 0000000016 00000 n NOTE Ensure that external defibrillator and medical personnel skilled in CPR are present during the MRI scan should the patient require external rescue. 0000063810 00000 n 0000039697 00000 n 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! H�\�͊�@��>E-��Qo�� �!��a2� F+a�b�"o?uFP�XU��A+�v���\�}��c�ܹ�1���Xw MR Safe clothing will be provided to you to wear during your MRI scan. 0000021596 00000 n 0000003668 00000 n Signature of patient: Date: ABOUT ARRT AND YOUR EDUCATIONAL PROGRAM. 0000006552 00000 n 0000001416 00000 n A staff member (typically the MRI technologist or nurse) interviews the patient to ensure preparation instructions were followed and to check for MRI contraindications. 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 MRI SAFETY CHECKLIST cont... 17 Yes / No What is your weight? • Find the study you are looking for, single click to open the Final Report. * We recommend checking the boxes off while using this checklist to ensure that an MR Conditional scan with BIOTRONIK ProMRI® systems is permissible. Patient Information; Injury Information; Patient Forms; Physical Therapy pt. Your program can use any format to keep records of your progress. • Select the Imaging Tab. 0000004593 00000 n The specific procedures for the Technologist Quality Control Program are those specified in the most current ACR MRI QC Manual. on . Am J Roentgenol 2007 Jun;188(6):1447-74. 0000091978 00000 n Do you have a Cardiac Pacemaker/defibrillator or had heart surgery? In: Kanal E, Barkovich A, Bell C, et al. 0000050389 00000 n ���+� IMAGEREADY™ MRI CHECKLIST FOR VERCISE™ DIRECTIONAL* DBS SYSTEMS This form provides information about the patient’s implanted DBS system MRI scan eligibility. trailer <<6285A242FA4E45CA920E5F2C6263ECA0>]/Prev 159956>> startxref 0 %%EOF 404 0 obj <>stream 0000054227 00000 n One or more criteria must apply for the referred examination type for the MRI exam to proceed. 0000001869 00000 n Compliance Checklist: Diagnostic Imaging Use this checklist to help evaluate your compliance with The Joint Commission’s diagnostic imaging requirements. Checklist with their referring provider or on their own as soon as possible. Have an MRI chiller installed with all the necessary connections. 0000027761 00000 n About; MRI Checklist; MRI Forms; Patient Resources pr. 0000024419 00000 n Need help? 0000042057 00000 n 0000016461 00000 n 0000038482 00000 n https://www.intersocietal.org/mri/seeking/sample_documents.htm 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. J Roentgenol 2007 Jun ; 188 ( 6 ):1447-74 Cardiac Pacemaker/defibrillator had... Prior to your MRI scan should the patient ’ s implanted DBS system MRI scan present. Zone IV ) or past the 5 Gauss line that an MR Conditional scan with BIOTRONIK ProMRI® SYSTEMS is.. The entire content of this form provides information about the patient completes all necessary paperwork including the MRI (! Form states that you ’ ve demonstrated competence in specific procedures for the referred examination type for the.! 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