Imaging Order/Referral (X-ray, MRI, or CT)

Date/Time: [order date and time]
Patient: [name, DOB, MRN]
Ordering Clinician: [name, credentials, callback number]

Order Details

Study: [modality + body region + laterality as applicable]
Contrast: [none / with IV contrast / without & with IV contrast]
Priority: [STAT / Urgent / Routine] (If Urgent or STAT, include brief rationale.)
Clinical Question: [single direct question for radiologist, e.g., "Rule out fracture," "Evaluate for disc herniation causing radiculopathy"]
Indication: [working diagnosis and/or key symptoms; include ICD-10 if required plus plain-language description]

(If ordering multiple studies, repeat the Order Details block for each study.)

Clinical Summary

[Narrative covering onset/duration, mechanism or precipitating factors, key symptoms with location and radiation, and relevant neuro features if applicable. Include context that materially affects imaging selection such as cancer history, immunosuppression, anticoagulation, prior surgery/hardware, or high-risk trauma.] (Limit to 2–4 sentences; include only details that influence imaging appropriateness or interpretation.)

Conservative Treatment: [type, duration, and response] (Include only if relevant to justify imaging; otherwise omit this field.)

Exam Findings: [pertinent positives and negatives supporting the indication or affecting urgency] (If exam not performed, state reason.)

Prior Imaging: [type, date, and key findings] (Omit if none.)

Safety Screening

(Include only elements relevant to the ordered modality. Do not infer safety-critical information; document "unknown" with plan if not verified.)

• CT or X-ray (radiation exposure): [pregnancy status: negative / positive / unknown]; [LMP or pregnancy test date and result per local policy] (If unknown and non-urgent, document plan to defer pending testing.)
• CT with IV contrast or MRI with gadolinium: [prior contrast reaction with type, severity, and agent if known]; [most recent creatinine/eGFR with date, or "unknown"]; [dialysis or CKD status if applicable]; [metformin use—for iodinated contrast only]; [premedication plan if indicated]
• MRI implant/metal screening: [pacemaker/ICD, aneurysm clips, neurostimulators, cochlear implants, retained metal/shrapnel, other devices with brand/model if known]; [implant status verified: yes / no / pending] (If not verified, document plan to complete MRI safety screening.)
• MRI tolerance: [claustrophobia: yes / no]; [ability to lie still]; [sedation needs]

Assessment

Suspected Diagnosis: [primary diagnosis]

Differential: [2–4 items if they change protocol or represent "can't miss" conditions] (Omit if not applicable.)

Management Impact: [how imaging results will guide next steps]

Red Flags: [list any present: progressive neurologic deficit, cauda equina symptoms, suspected infection, malignancy concern, vascular emergency] (Omit this field if none present.)

(For studies where critical findings are possible: "Please contact ordering clinician at [callback number] for critical results.")

(Omit any sections or fields that do not apply rather than leaving empty placeholders.)