diagnostic reqs

hi all,

just to mention again…ct req needed on paper only for contrast studies now, tech will pick up, no DI orders to fax for er patients anymore.

outpatient studies still need paper req as always…

actual memo attached….if you missed..
cheers,
john

Memo

To: All Nursing and All DI Staff

MAHC Physicians

From: Karen Fleming, Chief Quality & Nursing Executive

Esther Millar, Chief Executive Clinical Services

Harold Featherston, Chief Executive Diagnostics, Ambulatory & Planning

CC: Senior Leadership Team

Date: November 11, 2015

Re: Emergency Dept. / In-Patient Requisitions for Diagnostic Imaging

Since the launch of our Electronic Medical Record, all diagnostic imaging tests required the generation of an electronic requisition as well as the provision of either a scan of the physician’s order or a blue DI requisition. These measures were implemented to ensure the proper information was relayed to the DI department during the transition to the electronic record.

Nursing and diagnostic imaging staff has worked diligently since the summer to develop an electronic requisition that meets all the regulatory requirements for a DI order. Effective November 16th, for all DI tests except CT with contrast, mammography and interventional radiology, only the electronic requisition will be required. The power order is placed in Cerner and through Radnet the DI department can print from the electronic requisition as needed.

In order for the Power Order to include all the essential information, the nursing staff is required to ensure the following information is placed in the Comments section: • Past medical history as pertinent to the imaging request

• Contributing presenting information to inform radiologist, i.e. mechanism of force, injury, symptoms etc

• Special instructions as requested by the ordering physician; i.e. patient to see referring practitioner after imaging, 3 view chest, portable, timing (repeat in 3 days), with/without contrast, etc.

CT with contrast, mammography and interventional radiology require additional information. As a result, these procedures will continue to require paper requisitions to be filled out by the physician. Nursing will input the order into Power Order and the completed paper requisition is placed on the chart to be picked up by the DI technologist. There is no requirement to fax the ED cover sheet. Further development of the electronic requisition for CT is planned.

I would like to thank everyone for their patience while this issue was resolved and their commitment to providing the best care for our patients.