Request for Diagnostic Imaging Flowchart

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4/16 EXAMPLES

Text in this Example:

Imaging Request: Form Completion
A brief process overview
Gather patients name and verify identification
Answer any additional questions the patient may have
Physician signs off on the request form
MD to select diagnosis by using the codes listed
MD reviews patient records to complete diagnosis
Record Clinical indications for the exam
Is the study listed on the form?
Select which study is being performed
Imaging request form generated by MD or PA
Get contact information for nearest friend or relative
Patient is transferred to front office for form completion
Verify patients insurance, get prior authorization if applicable
Fill in personal info including weight, D.O.B, and phone number
Date of examination
Pre/Post Op?
Give patient confirmation of their appointment
Send request over to Radiology Ward
Schedule a date and time for the imaging request to be performed
Receive test schedule from Radiology Ward
Record office information/where this report will need to be sent back to
Date of Surgery
Specify the study to be performed in the box below