Class of 2012 Diagnostic Imaging Count Part 2

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1. Student Identification Number (Last Four)
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2. Date
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3. Location/Department where examination was performed:
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4. Examination:
5. Accession # or other Identification number that does not violate HIPPA
6. What was your involvement for this specific examination?
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Observed
Hands on
Performed Independently (Indirect/Direct supervision)
7. N/A
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8. Did you repeat a specific examination? If the answer is yes, please answer the next question.
9. Please provide the following patient information for REPEAT EXAMINATIONS ONLY:
10. Reason for Repeat
Inaccurate kilovoltage (kVp) calibrationInaccurate milliamperage (mA) calibrationInaccurate timer calibrationInaccurate automatic exposure control (AEC) responseDirty or damaged cassettesImproperly labeled or damaged gridsMalfunctioning collimatorsImproper film storageIncorrect or inconsistent film processingUse of incorrect technical factors (kilovoltage, millamperage, distance, time)Incorrect positioningFailure to measure the patient with caliperImproper collimationImproper use of accessories such as grids, cassettesImproper handling of unexposed or exposed filmFailure to communicate clearly to the patient to hold the breath or to hold still
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11. N/A
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