X-RAY REQUEST ENTRIES
BOTTOM OF FORM
1. Patient's full name.
2. Family member prefix +sponsor's SSN.
4. Unit/unit telephone number.
TOP OF FORM
5. Exam requested.
6. Patient's age.
8. Family member prefix + sponsor's SSN.
10. Film No. (=SSN).
11. Pregnancy status (female patients).
12. Requesting physician's name.
13. Requesting physician's signature.
14. Requesting physician's telephone/pager number.
15. Date requested.
16. Exam requested.
17. Specific reasons for request.
(Brief clinical history.)
Figure 4-13. Required entries that must be verified.
THE RADIOLOGIST'S REPORT
The middle blocks of the X-ray request slip will remain blank until the X-rays have
been taken, forwarded to the radiologist, and evaluated. Thus, you should only look for
these entries after the X-ray work has been completed. Once these steps have been
accomplished, check the middle blocks for accuracy and consistency. Look for the date
of the exam, the date of the report, the date of transcription, the radiologic report with
the radiologist's name, rank, and title in the middle blocks, as shown in figure 4-14.
Jumping down to the lower right-hand portion of the form, look for the location of the
radiologic facility and the radiologist's signature.