Sponsored research diagnostic order form.pdf

Ordering Physician/NP
) Bill Research Grant / Study:
WMC Account No._______________________ - _____________________________ RADIOLOGY
Principal Investigator's Name ____________________________________________ Principal Investigator's NYPH ID Code ____________________________________ ) Bill Patient / Insurance:
Use QV modifier & V70.7 secondary diagnosis TO BE DONE
PRIORITY 1, 2 or 3
Small Bowel
UGI Series
Bone Scan P
P Pt must be NPO 4 hrs. Requires BUN & Creatinine.
Clinical History __________________________________________________________________________________________________________________________
________________________________________________________________________________________________________________________________________ BUN ________________________________ Creatinine ____________________________________ Date __________________ for Pediatric Radiology (M-F 8am - 4pm) fax to 60138 - for Pediatric Cardiology fax to 68373 PROCEDURE ORDER FORM
Many of the Radiology examinations require that the patient be prepared for the procedure that is being
ordered. We have included a brief description of the most common procedures, HOWEVER, all exams
are included in the Manual of Laboratory, X-Ray, and Special Procedures and are contained in the
Ancillary Services section in this manual. The procedure in the manual contains a brief description,
indications, contraindications, patient preps and special instructions.
Please call Pediatric Radiology x62554 for modified preps for pediatric cases.
NOTE: SEQUENCING of exams is critical when ordering multiple exams. Barium studies generally should be done after other diagnostic procedures. See Manual for more complete information or discuss with Radiologist so as not to delay patient care.
G.I. Series
Prep: N.P.O. from Midnight day before study. Suspend all medication except essential. Antispasmodics should be discontinued 24 hours before procedure.
Aftercare: mild laxative and fluids.
Barium Enema
Prep: Clear fluids 24 hours prior to study, 60 ml magnesium citrate by mouth at 5 PM day before study.
4 bisacodyl tablets (Dulcolax) by mouth at 10 PM the night before exam.
1 bisacodyl suppository morning of exam.
Nothing by mouth after midnight.
I.V.P. (Intravenous Pyelogram)
Prep: 10 ounces of magnesium citrate at 6 PM evening before exam.
C.T. (Head & Body)
Prep: Clear fluids 4 hours prior to study. Contrast injection requires the patient be NPO for at least 4 hours prior to study. Patients must be cooperative and able to hold their breath for Body CT's.
Aftercare: Patients receiving contrast should be hydrated.
CONTRAINDICATIONS: 1. Patients over 300 lbs. 2. Patients with PACEMAKERS CANNOT BE DONE. 3. Patients with metal surgical clips and other prosthetic devices should consult with the Radiologist before ordering MRI's. 4. Claustrophobia and inability to remain still are also contraindication and sedation may be required. SEE MANUAL FOR COMPLETE DETAILS.
PELVIC/OBSTETRICAL: Requires full bladder. Patient should drink water and maintain a full bladder.
ABDOMINAL/AORTIC RENAL: Clear liquid diet for 24 hours prior to exam.
To obtain an adequate study, patient must be able to lie quietly for up to one hour in supine position. Adequate sedation is absolutely necessary in the restless patient.
For biliary, meckel's, cardiac, and any studies requiring sedation, the patient must be fasting fora minimum of four hours prior to test.
Radioactive iodine is used for thyroid uptake and scanning. Do not schedule test if any of the following drugs or foods have been ingested within minimal time limits indicated: Iodine Compound (Lugol's Potassium Iodids, Kelp): 1-2 weeksSeafood, Ovaltine, vitamin pills, Orande, Combid: 3-5 daysDiodrast, Hypaque (i.e., IVP's and arteriograms): 1-2 weeksPriodax. Telepaque, etc. (i.e. gallbladder series): 3-6 monthsLipoidal (i.e., bronchograms): at least 6 monthsAnti-thyroid drugs (i.e., Propylthiouracil, Tapazole): 7 days. If in preparation for urgent radioiodine treatment, consultation is advised.
Thyroid substance (i.e., desiccated thyroid, Thyroxine): 4 weeksTri-iodothyronine (Cytomel): 10-12 days.
If special circumstances require evaluation despite the above indications(contraindications) Nuclear Medicine physician consultation advised.
• This form MUST be used to order research related diagnostic radiology exams. It is also
required for research related Cardiology, Pulmonary, and Neurology services.
• Do not use the Sponsored Research Diagnostic Order Form for non-research related diagnostic services that are being ordered at the same time. Use the usual order process for non-research related services (i.e., prescription blank, other pre-printed order form, standard EPIC order process, etc.). • The red box on the upper left side of the form MUST be completed. The ordering physician (who will most likely be the Principal Investigator or a Co-investigator) must indicate how the research related service is to be billed. The choices are: Bill Research Grant/Study OR Bill Patient/Insurance
• “Bill Research Grant/Study should be marked if the sponsor is paying for the service. The selection of this option should be consistent with the protocol and the corresponding information provided on the clinical trials analysis form completed at the time the research study was approved or renewed. It should also be consistent with the financial responsibility information provided on the patient’s informed consent. • When selecting, “Bill Research Grant/Study”, the hospital technical component and the
corresponding professional component will be billed to the grant account for the research study. It is important to indicate the WMC Account Number for the research grant/study. This is a six-digit account number. A corresponding three-digit suffix assigned by NYPH (available after March 1, 2006) should be listed in addition to the WMC grant account number. Also list the Principal Investigator’s Name and the Principal Investigator’s NYPH ID code.
“Bill Patient/Insurance” should be marked if the research related service is considered “Standard
of Care” and is not be paid for by the study sponsor. When this is selected, the ordering provider
is indicating the service is medically necessary regardless of the fact that the patient is enrolled in a
research study. The hospital and physician fees will be billed to the patient and/or their insurance
as applicable. This should also correspond to the information provided on the clinical trial analysis
form as well as the information provided to the patient at the time of obtaining his/her consent for
research participation.
• Registrars cannot accept this form if the red box labeled “Mandatory Field” is incomplete as this information determines financial responsibility and ensures compliance with the grant/study billing. Failure to use this form when ordering research related diagnostic services or failure to use the form properly may result in any of the following: o Incorrect billing to the patient; o Incorrect billing to the research account; o Administrative inefficiencies while phone calls or other personal contacts are made to o Non-compliance reported to Office of Billing Compliance for a corrective action plan For more information, contact your department’s billing compliance representative or one of the following:
Please make sure the appropriate staff member has a supply of the SPONSORED RESEARCH
DIAGNOSTIC ORDER FORM available for your department’s use. Additional forms can be ordered
by using the approved NYPH order number on the left side of the form (51131).

Source: http://jcto.weill.cornell.edu/static_local/pdf/Sponsored_Research_Diagnostic_Order_Form.pdf

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