MRI Bariatric Patient Transport Checklist
This checklist, completed by the MRI technologist in consultation with the patient’s nurse, will
be used to identify clinical patient issues that might preclude safe patient transport to Mission
Bay Radiology for an MRI.
Patient Name: ____________________ DOB: _________ Unit: ______ Weight: ________
Is this patient’s widest diameter more than 70 cm or > 550 pounds?
Is this patient considered a Level 3 or ICU medical transport?
Is the patient hemodynamic unstable?
Does the patient require moderate or deep sedation?
Is the patient disoriented and/or non-cooperative?
Will there be medication drip(s) that cannot be stopped for >1 minute?
Are there needs for monitoring that are incompatible with the MRI environment?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
Yes
Yes
Yes
No
No
No
Yes STOP! This patient is not appropriate for transport to MRI.
Is the screening form missing or incomplete?
Are there any contraindications noted on the form?
Is the patient non ambulatory, and must transport by gurney?
All Yes answers must be cleared by MRI technologist prior to transport.
Comments:____________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
Please refer to the Bariatric MRI policy. Patients will be transported to Mission Bay for MRI in
accordance to the guidelines outlined in the policy, “Transport and Care of Adult Patients for Off
Unit Procedures”. If the patient is in a critical care unit, the patient must be accompanied during
transport by appropriate medical personnel including physicians and nurses. If the patient is not
ambulatory, the patient is to be transported by gurney, with a Hoover Matt placed under the
patient prior to transport.
eGFR:
<45
>45
Technologist : _______________________
Nurse:
________________________ Date: ___________________