Radiology Protocol Note (CT/MRI, Contrast)

Radiology Protocol Note

(Pre-acquisition clinical decision record documenting protocol selection and contrast safety. Do not include imaging findings or impressions.)

Protocoling Clinician: [name, credentials, role]

Date/Time: [date and time of protocol decision]

Ordering Clinician: [name and service/location]

Exam Ordered: [modality, body region, contrast status as ordered, urgency]

Protocol Status: [Approved / Approved with modifications / Pending / Deferred / Cancelled]

Indication & Clinical Question

[Clinical indication including patient context, symptom or diagnosis, and timeframe] (State succinctly in one sentence.)

• [Key clinical questions to be answered] (What needs to be ruled in/out, staged, or characterized; include 1-3 questions as applicable.)

[Clarification attempts and outstanding information] (Include only if indication is unclear from order; document who was contacted, when, and what information is still needed.)

Protocol & Contrast Plan

Selected Protocol: [modality, body region, protocol name, relevant phases/sequences tied to clinical question]

Contrast Decision: [IV contrast: yes/no; agent type; route] — [one-sentence rationale tied to clinical question]

• [Reason contrast withheld despite contrast-capable indication] (Include only if applicable.)
• [Variance from order: what was ordered vs. what will be performed; rationale; ordering clinician contacted yes/no with summary] (Include only if protocol differs from order.)

Safety Assessment

(Document only elements relevant to this patient and planned contrast. If safety-critical information is unknown, document as unknown and state action taken.)

• Renal function (when IV iodinated or gadolinium contrast planned): [Most recent eGFR or creatinine with date; AKI status; risk mitigation plan and responsible clinician if indicated; action taken if no recent labs available]
• Prior contrast reaction (if history present): [Reaction details: agent type, symptoms, severity, treatment required] [Mitigation plan: premedication regimen with timing feasibility, agent substitution, or enhanced monitoring]
• Pregnancy/lactation (when applicable): [Pregnancy status with method and date of determination; risk-benefit discussion if gadolinium in pregnancy; breastfeeding counseling if applicable]
• MRI safety (MRI only): [Implant/device MR compatibility status; foreign body screening if relevant; patient factors affecting feasibility; action plan if information pending]
• Metformin (if IV iodinated contrast with AKI or eGFR <30): [Hold/restart plan and responsible clinician]

Instructions

(Include only if preparation or technical requirements differ from routine department protocols. Omit section entirely if standard.)

[Non-routine preparation or technical requirements as applicable: breath-hold coaching, oral contrast/bowel prep, NPO status for sedation, IV access specifications, sedation coordination, isolation precautions]

Sign-Off

[Brief summary confirming final protocol, contrast plan, and key safety measures addressed]

Protocol Status: [Approved / Approved with modifications / Pending / Deferred / Cancelled]

Electronic Signature: [name, credentials, date/time]

Addendum: [Timestamped update describing protocol changes after initial documentation and reason] (Add only if changes occur after initial sign-off; do not overwrite prior decisions.)