Radiopharmaceutical Administration Record (Diagnostic)

Date/Time: [Date and time in YYYY-MM-DD HH:mm format]

Facility/Location: [Facility or imaging suite]

Patient Name: [Full name]

MRN: [Medical record number]

DOB: [Date of birth]

Second Identifier Verified: [Verification method used for second identifier]

Procedure/Protocol: [Study name and protocol]

Accession/Order Number: [Order identifier]

Patient Factors

• Weight: [Weight in kg]
• Height: [Height in cm or m] (Include when relevant for lean body mass or BSA calculations.)
• Relevant Allergies/Prior Tracer Reactions: [Allergy status] (If unknown, document "UTD" with reason.)

Pre-Administration Checklist

• Patient verification completed: [Yes / No] [Exceptions or comments if any]
• Pregnancy/lactation screening:
  • Status: [Negative / Positive / Not applicable / Unknown] (If unknown, document reason.)
  • Method: [Patient attestation / Test / Not obtained] (If not obtained, document reason.)
• Fasting status: [Confirmed / Not confirmed / Not applicable] [Fasting duration if relevant]
• Other relevant preparation: (Include only items applicable to the specific study.)
  • Hydration per protocol: [Yes / No / Not applicable]
  • Exercise restriction adhered: [Yes / No / Not applicable]
  • Caffeine abstinence adhered: [Yes / No / Not applicable]
  • Other study-specific prep: [Description or Not applicable]

FDG PET: (Include this subsection only for FDG PET studies; omit entirely otherwise.)

• Point-of-care glucose: [Value and units] at [Time of measurement]
• Diabetes/insulin management notes: [Details of timing and any deviations from protocol]
• Uptake environment: [Resting / Warm room / Quiet / Dim lighting / Other] [Additional notes]

Administration Block 1

(For multi-dose or multi-injection protocols, duplicate this block for each administration event.)

Radiopharmaceutical Details

(Do not infer radiopharmaceutical identity or activity; document exactly as measured. If any required field cannot be obtained, enter "UTD" with reason.)

• Radiopharmaceutical: [Radionuclide and ligand]
• Prescribed/Target Activity: [Value] [MBq] ([mCi])
• Assayed Activity: [Value] [MBq] ([mCi])
• Dosage Determination Time: [Date and time corresponding to activity measurement]
• Method: [Direct measurement / Decay correction]
• Person Determining Dosage: [Name and role or credential]
• Volume: [Volume in mL] (If captured.)
• Residual Activity: [Not measured / Measured: value and units] (If measured, note whether net injected activity was calculated.)
• Lot/Batch Number: [Value] (When available.)
• Expiration/BUD: [Date and time] (When available.)

Administration Event

• Route: [IV / PO / INH / ID / SC / Other]
• Administration Start Time: [Actual injection start time] (Do not substitute assay time.)
• Administration End Time: [End time] (Include for infusion or slow injection; omit for true bolus.)
• Site: [Device type] [Anatomic location with laterality]
• Administrator: [Name and role]
• Line Patency/Flush: [Brief notation]

Injection Site Assessment

(This section must always be completed; never leave blank.)

• Injection Uncomplicated: [Yes / No]
• Infiltration/Extravasation: [No / Suspected / Confirmed]

(If suspected or confirmed infiltration/extravasation, complete the following; otherwise state "Injection uncomplicated; no infiltration or extravasation suspected.")

• Evidence: [Swelling / Pain / Resistance / Lack of blood return / Imaging evidence / Other findings]
• Estimated extent: [Partial / Complete] [Mild / Moderate / Severe]
• Impact on study: [Proceed as planned / Delayed / Repeat dose considered / Scan rescheduled]
• Mitigation actions: [Local measures, monitoring plan, notifications made]
• Patient informed of event and symptoms to monitor: [Yes / No]
• Incident report completed: [Yes / No]

Administration Block 2

(Include only for multi-dose or multi-injection protocols. Remove this block if only one administration occurred. For additional events beyond two, duplicate block structure.)

Radiopharmaceutical Details

• Radiopharmaceutical: [Radionuclide and ligand]
• Prescribed/Target Activity: [Value] [MBq] ([mCi])
• Assayed Activity: [Value] [MBq] ([mCi])
• Dosage Determination Time: [Date and time corresponding to activity measurement]
• Method: [Direct measurement / Decay correction]
• Person Determining Dosage: [Name and role or credential]
• Volume: [Volume in mL]
• Residual Activity: [Not measured / Measured: value and units]
• Lot/Batch Number: [Value]
• Expiration/BUD: [Date and time]

Administration Event

• Route: [IV / PO / INH / ID / SC / Other]
• Administration Start Time: [Actual injection start time]
• Administration End Time: [End time] (If applicable.)
• Site: [Device type] [Anatomic location with laterality]
• Administrator: [Name and role]
• Line Patency/Flush: [Brief notation]

Injection Site Assessment

• Injection Uncomplicated: [Yes / No]
• Infiltration/Extravasation: [No / Suspected / Confirmed]

(If suspected or confirmed, document evidence, extent, impact, mitigation, patient notification, and incident report status as in Block 1.)

Adjunct Medications

(Include only when nonradioactive agents were administered as part of the imaging protocol; omit section entirely if none.)

• Medication: [Name] | Dose: [Value and unit] | Route: [Route] | Time: [Time] | Indication: [Protocol indication]
• [Additional medications as needed]

Immediate Adverse Events

• Immediate Adverse Event: [Yes / No]

(If Yes, complete all items below. If No, state "No immediate adverse events observed.")

• Event type: [Vasovagal / Allergic-like / Nausea or vomiting / Pain / Anxiety / Other]
• Onset time: [Time of onset]
• Severity: [Mild / Moderate / Severe]
• Interventions performed: [Description of interventions]
• Outcome: [Resolved / Improved / Ongoing / Escalated]
• Notifications made: [Who was notified and when]

Attestation

• Administrator Signature: [Name and credential]
• Date/Time: [Date and time of signature]

Attestations:

• Patient identity verified using two identifiers
• Radiopharmaceutical, activity, route, site, and times recorded as administered
• Complications and adverse events documented with appropriate notifications