Protocol Guidelines

Protocolling Exams

General philosophy:

We may 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 a more specialized 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 need.  Consider contacting the referring clinician in these cases.

Adding or removing IV contrast or body parts 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 was ordered but cannot be administered.

If you do add or remove contrast, or substantially tailor an exam, document why you did so and who was contacted in the medical record (on the protocol form in EPIC).

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

First year radiology residents:

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