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UNIT / CLINIC PACU

Inpatient

Outpatient | STAT URGENT (within 4 hrs)

CALL DEPARTMENT TO SCHEDULE | TODAY | TO BE SCHEDULED ON:

Date:

Inpatient Outpatient | |

| Portable Walk Wheelchair Stretcher |

|PRECAUTIONS: |

|Pregnant: YES: NO: ALLERGIES |

|Fall Risk Mental Status Changes Isolation |

|May remove immobilizing device during procedure |

|May discontinue Telemetry for transport and during procedure Other: |

| RADIOLOGY | INTERVENTIONAL | CT | MRI |

| |RADIOLOGY | | |

| | |WEIGHT (required) |WEIGHT ___(required) |

| |WEIGHT (required) | |Check all boxes that apply |

| | |Creatinine (required) |PACEMAKER or |

| |Creatinine (required) |Check all boxes that apply |DEFIBULATOR |

| |Check all boxes that apply |DIABETES |NEURO STIMULATOR |

| |ABNL RENAL FUNC. |ABNL RENAL FUNC. |METAL WORKER |

| |OTHER |B/P MEDS |ANEURSYM CLIPS |

| | |RECENT BARIUM |MRI SEDATION |

| | |STUDY |ANXIOLYSIS to be administered |

| | |Date |prior to MRI (only if pt. ( 65, |

| | | |>50 kg & low risk) |

| | | |LORAZEPAM 0.5–1.0 mg IV |

| | | |or |

| | | |DIAZEPAM 2.5–5.0 mg IV |

| | | |If PO anxiolytics are to be given to an |

| | | |inpatient, order on the floor order form. |

| | | |Moderate sedation needed (pt to |

| | | |be scheduled for procedural |

| | | |sedation with radiology RN). |

| NUCLEAR MEDICINE | | | |

| ULTRASOUND | | | |

|Check all boxes that apply | | | |

|PREGNANT: | | | |

|EDC by LMP of | | | |

|Prev US on at wks | | | |

|TRANSPLANT: | | | |

|Type: | | | |

|Date of TX | | | |

|EXAM REQUESTED: ANATOMICAL AREA OF INTEREST |CPT CODE | |

|R L Shoulder Xray: 1. Grashey AP | | |

|2. Axillary | | |

| | | |

| | | |

|SIGNS AND SYMPTOMS: MEDICAL NECESSITY/ SIGNS AND SYMPTOMS |ICD9 CODE | |

|Status Post Shoulder Arthroplasty | | |

| | | |

| | | |

|*Will call when ready. Thanks. | | |

| | | |

| | | |

|RELEVANT HISTORICAL DATA: ADMITTING DIAGNOSIS: |

|Surgery: Lab, X-Ray |

|DATE: TIME: 0700 ATTENDING PHYSICIAN (required) Frederick A. Matsen III |

|ORDERING MD SIGNATURE: UWP # 341750 BEEPER # |

|PLEASE PRINT NAME |

|FOR|TECHNOLOGIST COMMENTS: |PLACE EXAM FORM HERE |

|RAD| | |

|IOL| | |

|OGY| | |

|USE| | |

|ONL| | |

|Y | | |

| |FILM USED | |

| |14X17 |14X14 |11X14 |10X12 |9X9 | |

| |8X10 |CONTRAST USED | |

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