RADIOLOGY - INTERVENTIONAL CHECKLIST

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It is the responsibility of a qualified practitioner to complete, check and sign this list BEFORE the patient leaves the ward.

Date:
Ward:
Consultant: / Preferred name: / Hospital No:
DOB:

Proposed Procedure:…………………………………………………………………………………………

CHECK LIST
/

WARD CHECK

/

RADIOLOGY CHECK

Is Patient Diabetic?
(Please Circle) / Yes Ring 4844 or 4825 immediately for instuctions
No
/ Yes or No
Is Patient on Warfarin or Clopidogrel? / Yes Ring 4844 or 4825 immediately for instuctions
No
/ Yes or No
ID bands in place x2 and correct / Yes or No / Yes or No
Consent Form labelled, signed and understood / Yes or No / Yes or No
Intravenous cannula insitu / Yes or No / Yes or No
Last ate 6 hours pre-procedure
Clear fluids only up to 2 hours pre-procedure / Yes or No
Yes or No / Yes or No
Yes or No
Allergies (to include food/latex/medications etc) / Yes* or Nil Known
*Specify……………………………………………………………..………………………………….. / Yes* or Nil Known
*Specify……………………………………………………………..…………………………………..
For sedation/contrast purposes, any history of: (*circle if yes) / Asthma or Lung Problems
Angina or Heart Problems / Asthma or Lung Problems
Angina or Heart Problems
In-patient resuscitation status
(circle as appropriate) / For Resus or Not For Resus / Not for Resus status noted and communicated to team Yes
Blood Taken* (*see over for specific requirements) / Yes or No / Results obtained and communicated to team Yes
Correct Notes and labels with:-
Drug Chart*
IV Fluid Chart*
Fluid Balance Chart*
Observation Chart*
Diabetic Chart (if applicable)
(*Essential) / Yes or No / Yes or No
For out-patients list current medication……………………..……..……………………………………….……………………….…………………………………..
………………………………..……………………………………..
………………………………..……….…………………………….………….……………………….
Theatre Gown / Yes or No / Yes or No
Dentures – removed
Loose teeth/caps/crowns / Yes No N/A
Yes No N/A / Yes No N/A
Yes No N/A
Jewellery removed or taped / Yes No N/A / Yes No N/A
Print Name
Ext. No. / Print Name
Ext. No.

If the patient is infective e.g. MRSA+ and you think there is any other information we should know or if you have any questions about preparation, please contact a screening radiographer or member of the nursing team on ext. 4825 or 4844. SEE OVER FOR SPECIFIC PRE-PROCEDURE INSTRUCTIONS.

SPECIFIC PRE-PROCEDURE INSTRUCTIONS
  1. BLOODS REQUIRED
  • All tests within 2 weeks or within 24 hours if acutely unwell
  • INR/APTT same day if on Warfarin or Heparin

Procedure / Tests Required
All Patients on Warfarin
All Patients with known Clotting Disorder / INR
INR APTT
All Arterial Procedures / Arteriogram / Angiogram / Angioplasty / INR U&E/Creatinine
Central Venous Line but Only in Patients already on Chemotherapy / Platelets
Liver Biopsy
/ INR Platelets
US/CT Guided Biopsy or Drainage – other than Liver Biopsy / INR
Percutaneous Biliary Drainage / Biliary Stent Insertion / INR U&E/Creatinine Bilirubin
Nephrostomy / Ureteric Stent Insertion / U&E/Creatinine
Any Other Procedure / None
  1. NEPHROSTOMY/URETERIC STENT
  • IV Gentamicin 120mgs* 1 hour before procedure (conventional dose, give as bolus over 2 minutes)

Gentamicin Given / Yes or No
  1. PERCUTANEOUS BILIARY DRAINAGE
  • IV Hydration* minimum 1 Litre Normal Saline in previous 8 hours
  • Ciprofloxacin 750mg PO (IV Ciprofloxacin 200mg if patient unable to tolerate oral intake or concerns about gastric stasis)* 1 hour before procedure

IV Hydration Given / Yes or No
Ciprofloxacin Given / Yes or No
  • Ensure appropriately prescribed.If these instructions can not be followed, phone 4825 or 4844 immediately to speak to the screening radiographer or a member of the nursing team

OUT-PATIENT INFORMATION

Next of Kin Details / Name:
Contact Number:
Relative/Friend as Escort? / Yes or No
Someone at home? / Yes or No
Transport Home? (*Circle appropriate one) / *Own/Hospital Car Ambulance Bus Taxi

POST-PROCEDURE

Post procedure care guidelines given to ward staff / Yes or No
Cannula removed and site checked / Yes No N/A
Qualified Practitioner handing over / Print Name
Ext. No.
Qualified Practitioner receiving patient / Print Name
Ext.No