* We recommend checking the boxes off while using this checklist to ensure that an MR Conditional scan with BIOTRONIK ProMRI® systems is permissible. This will give you time to fill out your patient registration and final MRI screening forms and then dress for your MRI. 0000006105 00000 n ACR guidance document for safe MR practices: 2007. 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 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. (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. Contact the Standards Interpretation Group at (630) 791-5900 for assistance. 0000091978 00000 n MRI SAFETY SCREENING QUESTIONNAIRE (OUTPATIENTS) UCLA Form #10956 Rev. MRI Safety Checklist. 0000020012 00000 n Compliance Checklist: Diagnostic Imaging Use this checklist to help evaluate your compliance with The Joint Commission’s diagnostic imaging requirements. In: Kanal E, Barkovich A, Bell C, et al. • Find the study you are looking for, single click to open the Final Report. 0000079023 00000 n MRI UNIT. ���`)���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 Bold fi elds must be completed to avoid delays in patients processing. 0000003668 00000 n 0000006694 00000 n I confirm that I have answered all the questions and the information is correct to the best of my knowledge. Patient Prep Checklist Upon arrival, the patient completes all necessary paperwork including the MRI screening form and any relevant consent forms. 0000014634 00000 n 0000006552 00000 n �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*� 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 For questions, call 425.656.5550. Do you have a Cardiac Pacemaker/defibrillator or had heart surgery? 20 Are you breast-feeding? Checklist with their referring provider or on their own as soon as possible. • Select the Imaging Tab. The patient scanning process refers to the steps that must be followed to help ensure patient safety during an MRI scan. 0000005004 00000 n 0000021596 00000 n 0000004677 00000 n 0000024265 00000 n 6. Need help? MR Safe clothing will be provided to you to wear during your MRI scan. NOTE Ensure that external defibrillator and medical personnel skilled in CPR are present during the MRI scan should the patient require external rescue. 3. 1. ¨ Check the MRI Settings status (MRI Settings must be enabled before the scan). 0000038519 00000 n About; MRI Checklist; MRI Forms; Patient Resources pr. 0000016461 00000 n clothing and worn/removable items from your body. If yes, when was the most recent? trailer <<6285A242FA4E45CA920E5F2C6263ECA0>]/Prev 159956>> startxref 0 %%EOF 404 0 obj <>stream 0000042057 00000 n Patient Information; Injury Information; Patient Forms; Physical Therapy pt. 0000050428 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. 0000042809 00000 n 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. https://www.intersocietal.org/mri/seeking/sample_documents.htm 0000010391 00000 n 0000082952 00000 n 0000005116 00000 n Heart Pacemaker or Defibrillator Yes No *Aneurysm […] ¨ Disable the pulse generator MRI Settings. That form states that you’ve demonstrated competence in specific procedures at a specific time. 0000050389 00000 n 0000038482 00000 n 0000028034 00000 n Pre MRI Exam Checklist If you think you may be claustrophobic, ask your doctor to prescribe medication prior to the exam. 0000063810 00000 n Do you have aneurysm clips in your brain? Your MRI will take about 45 minutes, so plan on being at the MRI imaging center for around one hour. 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. on . H�\��j�0��~ IMAGEREADY™ MRI CHECKLIST FOR VERCISE™ DIRECTIONAL* DBS SYSTEMS This form provides information about the patient’s implanted DBS system MRI scan eligibility. 0000024419 00000 n The specific procedures for the Technologist Quality Control Program are those specified in the most current ACR MRI QC Manual. Signature of patient: Date: H�\�͊�@��>E-��Qo�� �!��a2� F+a�b�"o?uFP�XU��A+�v���\�}��c�ܹ�1���Xw 0000001869 00000 n 0000039697 00000 n 0000085651 00000 n 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. ���+� It may be provided to the radiologist to support the confirmation of the patient’s MRI scan eligibility. H�\��n�0��~ 0000005231 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. Have you had a previous MRI scan? ��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 Failure to disclose information could result in serious injury. 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). Select the Correct Scan Parameters for your MRI equipment. ]��]�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 The chiller may be provided as part of the deal, or you may need to purchase one yourself. If the answer to any of the questions on the MRI Safety Checklist is YES, please call 919 … Appendix 3: safety screening form, MR hazard checklist, and patient instructions. /�EEB��VBHi�JY̏&3@�I�@Y�����# �_[߁K��mwC?��g�}����/�5���̲�]����|m��d 0000004977 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. 0000054227 00000 n 2. Follow our simple actions to have your Mri Checklist Form well prepared rapidly: Find the template from the catalogue. Am J Roentgenol 2007 Jun;188(6):1447-74. 0000005345 00000 n Please provide a … 0000028207 00000 n 0000040362 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. Magnetic Resonance Imaging mri. To go back and review the completed checklist, go to the Imaging tab in Chart Review. A staff member (typically the MRI technologist or nurse) interviews the patient to ensure preparation instructions were followed and to check for MRI contraindications. 0000001416 00000 n 01737 231610. and leave a message, including your full name and contact details. 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 YES NO 2. Enter all required information in the required fillable fields. 0000035833 00000 n About; MRI Checklist; MRI Forms; Patient Resources pr. 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! Have an MRI chiller installed with all the necessary connections. I have read and understand the entire content of this form. YES NO 3. ���+3�� z�&�M؛�7ao�ބ� z��ͣ7OggOggOggOggOggOggOggOOOe?�~�,K�R��,K�R�T��2Y ¨ Perform the scan and monitor the patient. 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). 0000004593 00000 n %PDF-1.4 %���� 0000031182 00000 n 10. 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. One or more criteria must apply for the referred examination type for the MRI exam to proceed. ���+� 0000109337 00000 n MRI SAFETY CHECKLIST cont... 17 Yes / No What is your weight? 0000027761 00000 n Magnetic Resonance Imaging mri. At the bottom of the report, you will see the form history of who completed the form. Patient Checklist for MRI Please arrive 15 minutes before your exam time. Patient must be continuously monitored during the MRI scan by pulse oximetry and/or electrocardiography. Do not take the Merlin Programming system into the MRI room (Zone IV) or past the 5 Gauss line. Is your weight answered all the questions and the information i have provided is correct the! 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