X-Ray Imaging Protocol Checklist Form
X-Ray Imaging Protocol Checklist
Date of Procedure
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient Initials
*
Referring Physician
X-Ray Type
*
Please Select
Chest
Abdomen
Extremity
Spine
Skull
Other
Area to be Imaged
*
Protocol Checklist
*
Patient identity and order verified
Relevant previous imaging reviewed
Correct positioning confirmed
Exposure parameters set
Radiation protection applied
Technologist Name
*
Additional Notes
Submit Checklist
Should be Empty: