Chest X-Ray Workflow Documentation
Document each step and outcome of the chest X-ray procedure for quality and workflow tracking.
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Medical Record Number (MRN)
*
Ordering Physician
*
Date and Time of Chest X-Ray
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Hour Minutes
AM
PM
AM/PM Option
Radiographer/Technician Name
*
Type of Chest X-Ray
*
Please Select
PA (Posteroanterior)
Lateral
AP (Anteroposterior)
Portable
Other
Was contrast used during the procedure?
*
Yes
No
Equipment Used
*
Please Select
Fixed X-Ray Machine
Portable X-Ray Machine
Digital Radiography (DR)
Computed Radiography (CR)
Other
Image Quality Assessment
*
Excellent
Good
Acceptable
Poor
Findings / Observations
*
Any Follow-Up Actions Required?
*
Yes
No
If yes, please specify follow-up actions
Attach Chest X-Ray Images or Reports (if available)
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