CT ELECTRONIC PROTOCOL PROCESS
1.Ordering provider enters a radiology order and completes the CT Order Template. The Radiology Orderwith the completed CT Order Template prints in room 1291
2.MSA checks location and type of exam.
a.Inpatient, ED, Stat orders are to be taken to the radiologist to be protocoled immediately. Once the Inpatient, ED, Stat order is protocoled, the MSA is to take protocoled order to CT. Note - You will still follow the established procedure for handling these types of orders for the Noon- 1:30p timeframe.
b.If patient presents to schedule an appointment and order is not yet protocoled, the order is to be taken to the radiologist to be protocoled immediately OR call the reading room and provide the radiologist with the patient information. If patient calls and order is not yet protocoled, ask the patient for a contact number that s/he may be reached in the next 15-30 minutes. Take order and/or call radiologist to have it protocoled, immediately contact patient to schedule the appointment. Note - during the time the radiologists are at lunch and/or in conference, if youhave a patient to present toschedule a CT appointment and the order is not protocoled, you are to page the radiologist providing patient’s full name (Last, First, MI), SSN, and DOB, and the procedure.The radiologist will protocol.
c. Non inpatient, ED, Stat orders are to be taken off the printer separated by body part, and dropped off (there is a IN box and OUT box) at the appropriate reading room by 9:30a, 11:00a, 2:00p, and pickedup accordingly, e.g., when you drop off 11:00a, you are picking up orders dropped off at 9:30a, etc. You may drop off CT orders after 2:00pm but annotate on the order the drop off time, any order dropped off after 3:00p is not to be counted in the daily protocol tally.
d.You are not to put “today’s CT orders” in the draw tobe protocoled the next day. The goal is to get the CT orders protocoledASAP so the protocol is in CPRS before you schedule the patient.
3.Radiologist creates RADIOL/CT PROTOCOL/RADIOLOGIST note (CPRS).
4.Patient calls or presents to Scheduling Window(s) to schedule a CT appointment, MSA looks in CPRS to determine if order was protocoled. Note: Be sure you are looking at the correct protocol; ensure the order and the protocol match.
5.If the procedure was protocoled to include Oral and/or Iodinated Contrast, the MSA creates RADIOL/CT/PATIENT SCHED QUESTIONNAIRE template. If the procedure does not require Oral and/or Iodinated Contrast Patient Sched Questionnaire is not required.
To create the RADIOL/CT/PATIENT SCHED QUESTIONNAIRE template:
a.Open the RADIOL/CT PROTOCOL/RADIOLOGIST note for the procedurethe patient wants to schedule. Note: Be sure you are looking at the correct protocol; ensure the order and the protocol match.
b.Right click on the RADIOL/CTPROTOCOL/RADIOLOGIST Note, click Make Addendum.
c.Click Templates tab (left side of screen), Shared Templates, cursor down to Radiology (it may have a +, if so, click on the +), select and double click RADIOL/CT/CT/PATIENT SCHED QUESTIONNAIRE template.
d.Identify who will be answering the questionnaire, e.g., patient (which is the default answer) or type in who you are speaking to, e.g., Social Worker, Spouse, Caretaker, etc., and ask the questions and indicate answers.
e.If any of the responses to the questionnaire indicate information that is different from that given by the ordering provider on the CT Order Template and/or will change the CT Protocol, MSA is to contact the radiologist, and indicate the radiologist spoken to. Radiologist is required to addend the protocol to identify the new protocol and/or plan.
f.Click Exam Scheduled. If there are any comments you may enter in the space provided for free text.
g.When you have completed the template, Click Finish, right click on the addendum, select Sign NoteNow, and enteryour electronic signature code.
6.Annotate the order with the patient’s appointment date and time (use MM/DD/YYYY format, e.g., 04/15/2013; for time indicate AM or PM, e.g., 4:00pm). If the patient requires restrictions, send a copy of the Patient’s Instruction along with Appointment Letter to the patient. If there are no restrictions, write No Restrictions at the top of the order.
7.In addition, if the patient has restrictions, attach a separate Patient Instructions form to the CT Order. Select the applicable instructions relative to the patient’s procedure. Place the Patient Instruction form on top of the CT order. File the attached Patient Instruction and CT Order in the Schedule Folders by Schedule Date. This information will be conveyed to the patient when called to remind them of their appointment.
8.If the MSA identifies the ordering provider failed to correctly answer / complete the CT Order Template a Patient Event Record (PER) will be entered. For example, the patient’s record indicates s/he is a diabetic and is on Metformin, but the ordering provider responded “No” to the Metformin screening questions.
9.If the Radiologist failed to correctly respond to the protocol questions, MSA is to notify HSS and/or Chief Radiology.
10. Patient presents for his procedure,the CT Tech will create RADIOL/CT/TechNote.To create the Note:
a.Log into CPRS and enter patient name, select patient
b.Go to Note tab (bottom of screen) (if not already opted)
c.Select New Note
d. Select New Visit tab, at Visit Location, type in RADIOL (not case sensitive)
e.Select RADIOLOGY CT PROTOCOL-X (only use this location), select OK.
f.Select Note Title – RADIOL/CT/TECH NOTE, select OK.
g.Select from the drop down list the type of CT exam to be performed.
h. Under ADDITIONAL RAD TECH DOCUMENTATION section, select the type of CT ordered, e.g., Without Contrast, With IV Contrast, With and Without IV Contrast, With Oral Contrast, With IV “AND” Oral Contrast.
i.Go through the questions associated with the type of CT ordered. Each type of CT ordered will have applicable questions relative to the procedure. All questions are to be answered. Questions indicated with an * are required responses.
j. Review Allergies, Active Medications, Labs, etc., and annotate responses as applicable.
k.Complete the IV CONSTRAST ADMINISTRATION DETAILS section.
l.When you have completed the note, Click Finish, right click on the note, select Sign Note Now, and enter yourelectronic signature code.
11. After the procedure is completed, you would create the RADIOL/CT/TECH POST NOTE. To create the new note:
a.Log into CPRS and enter patient name, select patient
b.Go to Note tab (bottom of screen) (if not already opted)
c.Select New Note
d.Select New Visit tab, at Visit Location, type in RADIOL (not case sensitive)
e.Select RADIOLOGY CT PROTOCOL-X (only use this location), select OK.
f.Select Note Title – RADIOL/CT/TECH POST NOTE, select OK.
g.Select the appropriate post exam option either IV CONTRAST POST EXAM DETAILS or ORAL CONTRAST POST EXAM DETAILS.
h. Go through and respond to each question. All questions are to be answered.
i.When you have completed the information, Click Finish, right click on the addendum, select Sign Note Now, and enter your electronic signature code.
PROTOCOL NOT USED TEMPLATE
Any protocol that is not used must have an Addendum added to reflect the non-use. The MSA canceling the corresponding order will be responsible for creating the addendum.
1.After canceling the order, MSA will create an Addendum:
a.Openthe RADIOL/CT PROTOCOL/RADIOLOGIST template that is to be disused.
b.Right click on the Protocol Note, click Make Addendum.
c.Click Templates tab (left side of screen), Shared Templates, cursor down to Radiology (it may have a +, if so, click on the +), select and double click RADIOL/CT/Protocol Not Used template.
d.Select from Drop Down menu the reason the protocol is not being used. If the reason is not listed in the drop down list, select other and type in the specific reason in the free text area. Use standard cancelation reasons already in place.
e.Click Finish, when you exit you will be required to sign the Addendum.
2.If the reason the Protocol is not being used is because the patient did not call to schedule and the order is 30 days or older, if the patient calls within the two week grace period, MSA will follow standard procedure of re-entering an order (using the initial order information), and will submit the order to the radiologist to have it protocoled. The previous protocol is not to be used.
04/09/13