When health turns a page towards more critical evaluations, forms like the H MR 1097 become crucial. This particular form serves as a gateway for patients needing invasive radiology procedures through the VCU Health System, centralized in Richmond, Virginia. It is meticulously designed to gather essential patient information, starting from basic identifiers to more complex medical conditions and requirements. The form captures the patient's name, medical record number, date of birth, weight, and contact information, ensuring a comprehensive approach to patient care. It also delves into specifics about the required procedure or study, including its exact location and the side of the lesion, a critical step for accurate diagnosis and treatment planning. The form further inquires about the patient's ability to consent, any allergies, particularly to medication or contrast materials used in radiological procedures, and pre-existing conditions that could affect the procedure's outcome. This form not only addresses concerns such as potential medication interactions, notably with anti-coagulants, but also evaluates the patient's recent lab tests to ascertain their readiness for sedation or biopsy. Moreover, it doesn't overlook logistical aspects, emphasizing the importance of on-time arrival, NPO status (a medical term indicating that a patient must not take food or drink), and ensuring a responsible individual is available for transport home post-procedure. The completion and submission of this form are critical steps in the preparation for a radiological procedure, making the H MR 1097 an indispensable part of patient care coordination within the VCU Health System.
| Question | Answer |
|---|---|
| Form Name | Form H Mr 1097 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | InvasiveRadiolo gy mcv radiology email address form |
Name
MR #
Patient Identification
VCU Health System
MCV Hospitals and Physicians
Richmond, Virginia 23298
Invasive Radiology Request
DOB: _________ Pt weight < 300 lbs YES NO Patient Contact Phone #_________________
Procedure/Study to be done with specific location / side of lesion:____________________________________
__________________________________________________________________________________________
Diagnosis/Indication: ____________________________________
1. Can patient consent for procedure? YES |
NO Next of Kin/Contact# _______________________ |
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2. |
Medication or Contrast Allergy: |
YES |
NO __________________________________________ |
3. Contact Precautions? YES |
NO ________________________________________________ |
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4. |
Currently taking |
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5. Does patient have all of the following lab test results (within 30 days): YES NO |
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BUN _______ Creatinine ______ |
Platelets _______ PT ________ PTT _______ INR ________ |
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(Blood work is only needed for biopsies requiring sedation and/or pt taking anticoagulant medications)
6.Does patient require any special accommodations? YES NO ___________________________
•Radiology reserves the right to cancel and/or reschedule patient if:
(1)lab results are not posted within 24 hours of scheduled exam date
(2)if patient is 1 hour late for scheduled arrival time; or
(3)lack of transport home.
•Referring physician’s instructions to patient should include NPO status,
______________________________________________________________________ _____________ |
_____________ |
|
Requesting Physician: Printed Name and Signature / Pager |
Date |
Time |
Office/Clinic Contact Person: ____________________________ |
Phone #: ______________________ |
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Office/Clinic VM Location: _______________________ |
|
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When you have completed this form: Fax Completed Request Form, H&P/Clinic Notes, Current Medication List and Lab Results (within 30 days) to:
Contact Phone Numbers:
Medical Record Copy |
|
Radiology |
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