Documentation/Radiology
Module guide · Clinical
Radiology
One imaging order's full path: placed by a clinician, scheduled and worked by a technologist, read and signed by a radiologist, with contrast, radiation dose, and critical-finding safety steps tracked along the way.
What this module is for
Orders, Reports, and Scheduling are visible to a broad set of clinical staff who need to place orders and see results. Worklist and the Radiation Dose registry are limited to radiology staff and management.
Who uses it
Physicians, nurses, NPs and PAs place orders and read reports. Radiology technologists work the worklist and perform exams. Radiologists sign reports, amend them, and acknowledge critical findings. Schedulers book appointments.
Where to find it
Open Radiology from the sidebar. Six screens: a dashboard, Imaging Orders, Worklist, Reports, Scheduling, and Radiation Dose.
- 1
Order
A clinician places an imaging order with a modality, body part, and clinical reason.
- 2
Schedule & perform
The order is scheduled, the patient arrives, and a technologist starts and completes the exam, uploading images.
- 3
Report & sign
A radiologist drafts findings and an impression, then finalizes and signs the report.
- 4
Follow up
Critical findings must be acknowledged with a documented read-back; contrast reactions and radiation dose are logged along the way.
A few terms you'll see throughout
Dashboard
Surfaces what needs attention right now: overdue STAT orders, missing reports, and unacknowledged critical findings.
Stat tiles
| Field | What it means |
|---|---|
| Overdue STAT | STAT orders pending more than 1 hour without being worked. |
| Awaiting Report | Exams completed more than 4 hours ago with no report yet. |
| Unacknowledged Criticals | Critical findings without a documented TJC read-back. |
Clicking an overdue order or unacknowledged finding jumps straight to it on Orders or Reports. Quick-nav cards link to the other five screens.
Imaging orders
Create orders and manage every step of one: arrival, exam, image upload, report drafting and sign-off, contrast/dose recording, and full history.
"New Imaging Order" form
| Field | What it means |
|---|---|
| Patient, Ordering Physician* | |
| Modality, Body Part* | 24 modalities, e.g. X-Ray, CT, MRI, Ultrasound, PET/CT, Mammography, DEXA, and more. |
| Laterality | Left, Right, Bilateral, Unilateral, or Not Applicable. Defaults Not Applicable. |
| Clinical Reason* | |
| ICD-10 Primary, CPT Code | |
| Priority | STAT, Urgent, Routine, Elective, or ASAP. Defaults Routine. |
| Contrast required | Checkbox; reveals a required Contrast Agent field (18 options, e.g. Iohexol, Gadobutrol, Barium Sulfate). |
| Patient Prep, Performing Location, Ordering Notes |
The order detail drawer has four tabs: Overview, Images, Report, History.
Overview tab — workflow actions (status-gated)
| Field | What it means |
|---|---|
| Mark Arrived | While Pending/Scheduled. |
| Start Exam | While Arrived; requires picking a technologist first. |
| Complete Exam | While In Progress; optional technologist notes. |
| Cancel Order | Any status except Finalized/Cancelled, these two are terminal. Requires a typed reason. |
| Record Contrast Reaction / Record Dose | Always available, independent of order status. |
Images uploads photos/DICOM/PDF files, stored locally on the hospital's own server, no PACS or cloud dependency. Report drafts Findings and Impression, flags a Critical finding (with a required description), then Finalize & Sign. A finalized report can only be changed via Amend (with a reason) or a standalone Addendum, never a silent edit.
Acknowledging a critical finding
Pending / Scheduled — ordered, not yet started
Arrived / In Progress — patient present or exam underway
Completed / Reported — exam done, report attached
Finalized — report signed, locked
Cancelled / Discontinued — called off
Worklist
A prioritized, real-time queue for assigning radiologists, technologists, and rooms to active studies. Radiology staff only.
Filter by radiologist; each row shows patient, study, priority, status, and current room, with Teaching Case, Quality Review, and Read flag icons where set. Assign opens a small form to set or change the radiologist, technologist, and room, purely a staffing action, it doesn't change the order's clinical status.
Reports
Look up a finalized report by accession number, and manage acknowledgement of unacknowledged critical findings hospital-wide.
Look up by accession
Type-ahead search finds a finalized report and shows its findings, impression, and radiologist; a critical, unacknowledged report shows an Acknowledge button right there.
Unacknowledged Critical Findings (TJC)
A hospital-wide worklist, confirming read-back "in accordance with Joint Commission requirements" per finding. No form fields, just a confirmation dialog.
Scheduling
Finds an already-placed order by accession number and books its appointment time, technologist, and room.
Appointment form (after finding an order)
| Field | What it means |
|---|---|
| Scheduled Start, Scheduled End* | |
| Technologist, Room, Notes |
This screen only books the appointment slot for an order that already exists, it can't create a new order. Submitting resets the form for the next lookup.
Radiation dose registry
A per-patient cumulative radiation dose history, ACR Dose Index Registry (DIR) compatible, for tracking lifetime/annual exposure. Radiology management only.
Dose history columns
| Field | What it means |
|---|---|
| Exam Date, Modality | |
| CTDIvol (mGy), DLP (mGy·cm), Effective Dose (mSv) | |
| DRL Status | "Exceeds DRL" (red) or "Within DRL" (green), against the Diagnostic Reference Level. |
| Alert | A red ALERT badge if this exam triggered a dose alert. |
ALARA warning banner
This screen is read-only history, actual dose values are recorded per exam from the Imaging Orders detail drawer's Record Dose action. Export CSV downloads one patient's dose history.
Good practices
Pick a technologist before starting an exam
Acknowledge critical findings promptly
Amend, don't re-draft, a signed report