Protocol Guidelines

Protocolling Exams

General philosophy:

We tailor exam protocols to a more specific protocol than ordered to the benefit of clinicians and patients (ie change an MR brain w/wo contrast to an MR Brain MS protocol w/wo contrast).

Extreme caution should be made when considering changing an order from a specialist physician, as they typically order the exam they think they need.  Consider contacting the referring clinician in these cases.

Adding or removing IV or PO contrast should generally only be done after discussion with the referring clinician. Rarely, the radiologist may need to make a decision as to whether to postpone an exam or do a non contrast exam when the referring clinician cannot be reached. Attempts should be made to contact the referring physician as they may prefer an exam of a different modality (MR vs CT) if contrast cannot be administered.

If you do end up unilaterally adding or removing contrast, document why you did so in the medical record (protocol viewer).

If you substantially change or tailor an exam beyond what is indicated in the reason for exam or EPIC notes, document why and with whom you spoke in protocol viewer so that if a question arises later, we know why the ordered was changed.

Key criteria to check when protocolling exams

  • Exam actually ordered
  • Reason for exam
  • "Comments"
  • FOR BODY EXAMS: whether Oral contrast is permissable. This is specifically listed in a separate field on the order. If yes, then a route of administration is listed in the next field.
  • Referring clinic/physician
  • Patient age
  • Outside orders - if it is an outside order, read the actual order especially for contrast - yes, no, or at radiologist's discretion. Verify that the order put into the system matches the actual physician order.
  • Prior exams

Verbal protocols:

Verbal protocols will be returned in "protocol viewer" in the "to be cosigned" list for each radiologist. These must be signed within 48 hours by state law, so please check this at least daily.

First year radiology residents:

First year resident protocols are to be checked by a more senior resident, fellow, or faculty.

See Radiology IT resources page