Radiology Technology Program/MRI Certification
S T U D E N T C O M P E T E N C Y E X A M I N AT I O N
Student
Examination
Patient's Name (place student sticker here)
Date
Patient Number
First Attempt
Yes
No
If No, why?
Yes
No
3. Did you request this competency before you saw the patient?
Yes
No
1. Whom did you notify that you wanted to comp this examination?
2. Was this technologist with you for the entire examination (from patient entering room to exit)?
4. How many related examinations have you completed before requesting this competency?
0-1
2-4
5+
10+
If less than 5, why?
5. Estimate the level of difficulty for this examination?
1 (Easy)
2
3
4
5
6
7
8
9
10 (Difficult)
Why did you give this level of difficulty?
6. How did you identify the patient for this procedure?
7. Did the patient need preparation before entering the room?
If Yes: What was done or what did you do?
Yes
No
Yes
No
8. What is the patient’s history?
How did you obtain this information?
9. Was the examination modified from the initial order?
10a. If Yes: Why?
10b. Modification approved
by:
11. Were there any complications?
If Yes: Explain:
Yes
No
Yes
No
12a. Did you receive any assistance during the examination?
If Yes: Explain:
12b. Did the technologist intervene in any way?
If Yes: How?
Yes
No
12c. Did the technologist change or assist you in your technique or positioning (verbally or non-verbally)?
If Yes: What or how?
Page 1 of 2; Student Competency Examination
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Yes
No
Created: 12/1/2015; Rev: 12/3/2015
Student Competency Examination
13. Did you have any repeats?
Yes
If Yes: Which projections and why?
No
14. What could have been done to improve this examination?
15. Identify the following examination parameters:
If Contrast Used:
Type
Mode of Transportation
Stretcher/WC/Ambulatory
Oxygen
IV
Yes
Amount
Reaction (if yes, see #10)
No
Yes
No
Administered by
Standard Precautions Used:
Patient Needs Attended To:
Room
Time In
Time Out
Length of Exam Only
List other exams done on this patient besides the competency exam:
Projection (ex: PA, LAT)
IR size (ex: 8X10 – crosswise)
Technique: kV (ex – 85kV)
Technique:
As or AEC & Density Setting: 3.2 mAs OR +2
SID (ex:40")
CR Angle used (ex: 15 caudal)
Shielding (Radiation Protection)
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
For CR Competencies
Exposure Value (Index or S number)
Algorithm originally used (ex: PA Chest)
Algorithm used if correction needed (ex: Skull)
Time image acquired (processed)
Time image delivered to PACS
Person delivering Image to PACS
Adjustments after acquisition (Ex: electronic
marker, masking, contrast/density)
Additional Comments
SIG NAT URE
Students signing this form are verifying that all of the above information is true to the best of their knowledge. Any falsification may mean
dismissal from the program due to falsification of information.
Student Signature
Page 2 of 2; Student Competency Examination
TMCC is an EEO/AA institution. See http://eeo.tmcc.edu for more information.
Date
Rev.: 12/3/2015