CHILDREN’S HOSPITAL OF THE KING’S DAUGHTERS, INC.
601 Children’s Lane, Norfolk, VA 23507-1910
Radiology Department
GENERAL RADIOLOGY STUDY ORDERS
AND DOWNTIME FORM
Wt :________ kg
Ht :________ cm
Patient Label or MRN, Acct#, Patient Name, DOB, Date of Service
Allergies:
NKA or ___________________________________________
Pregnancy Status per lab request:
Positive
Negative
N/A (Male, Premenarche, Distal film (elbow or knee)
Precautions/Isolation:
Droplet
Airborne
N/A
Contact
Call Critical Results or Questions to: *Please provide a phone number or pager number that can be reached at the time of the examination and/or reading
Information you wish to gain from this study:
Pertinent Clinical/Surgical History and Physical Exam Findings:
Date needed: _________________
Exam Requested 1:
Routine
Urgent
Stat
Portable film (PICU, NICU, pt is unstable)
If needed: indicate contrast type below
With IV contrast
Date needed: _________________
(must be for same indication as above or use a separate order form)
Exam Requested 2:
Routine
Urgent
Stat
With and Without IV contrast
With PO contrast
Portable film (PICU, NICU, pt is unstable)
If needed: indicate contrast type below
With IV contrast
If IV contrast is ordered indicate type of Line access:
Yes
Floor/Unit TO ACCESS:
If needed:
No
OR
Needs IV
PIV
Sedation RN TO ACCESS:
CVL
Physician Signature
STUDY
CT head WITHOUT contrast
CT abd/pelvis W/OUT contrast
CT abd/pelvis WITH contrast
CT orbits WITHOUT contrast
CT orbits WITH contrast
CT facial bones
CT mandible
CT temporal bones w/o
contrast
CT temporal bones w/
contrast
Port
Yes (Must fax Flush orders)
Sedation (Available M-F 7a-3:30p call 668-7680 to schedule) or
Date and Time
With and Without IV contrast
With PO contrast
No
Anesthesia (Contact 668-7320 for availability)
Print Physician Name
GUIDELINES TO ORDERING THE APPROPRIATE RADIOLOGIC STUDY
Indication(s)
STUDY
PIC(Simon)/Pager #:
Indication(s)
Trauma (skull fracture, intracranial
hemorrhage), Hydrocephalus (VP shunt
malfunction)
Renal stones
Chest L\R lateral decubitus
Lower airway foreign body, pleural
effusions
Abdomen 1 view
Appendicitis, intra-abdominal abscess, intraabdominal pelvic tumor
Trauma – Orbital fracture, globe injury
Infection such as (peri)orbital cellulitis, tumor
Fracture of facial bones (includes orbits,
midface, and mandible)
Fracture mandible
Basilar skull fracture
Bone survey
Constipation/gallstone/fecalith/renal
stone
Suspected non-accidental trauma in
children less than 2 years old
Shoulder dislocation
Patellar Fracture/dislocation
Usually ordered in conjunction with CT
Head WITHOUT contrast
Requires Foley catheter in place.
Dental disease. Requires transport to
SNGH. Order in consultation w/
dentist or OMFS.
Scapula Y view
Knee, Sunrise view
Shunt series
Pelvic US (trans-abdominal)
Panorex
Mastoiditis
Amer Coll of Radiology Diagnosis Guidelines: http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx
CHKD Form 2421 MR Rev 1/11