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Mink Information
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MDRH Referral
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STAT
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Radiology Co. Please assist in Authorization
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ORDER 1
• • •
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Side
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Body Part
• • •
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WITH CONTRAST?
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Creatine Level (include date)
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Other Order
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Diagnosis
• • •
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Other Diagnosis/ Rule out
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Notes
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For Pre-Op Assessment?
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Has Patient Tried PT?
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< How long?
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Give patient CD?
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Give Patient Films (MDRH only)
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ORDER II
• • •
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Side
|
|
Body Part
• • •
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WITH CONTRAST?
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|
Creatine Level (include date)
|
Other Order
|
|
Diagnosis
• • •
|
Other Diagnosis/ Rule out
|
|
Notes
|
For Pre-Op Assessment?
|
|
Has Patient Tried PT?
|
< How long?
|
|
Give patient CD?
|
Give Patient Films (MDRH only)
|
|
ORDER 3
• • •
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Side
|
|
Body Part
• • •
|
WITH CONTRAST?
|
|
Creatine Level (include date)
|
Other Order
|
|
Diagnosis
• • •
|
Other Diagnosis/ Rule out
|
|
Notes
|
For Pre-Op Assessment?
|
|
Has Patient Tried PT?
|
< How long?
|
|
Give patient CD?
|
Give Patient Films (MDRH only)
|
|
Salutation - Khurana
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