1. OnLine Forms or Medicals

2. O N L I E F R M SHMC MURPHY HELEN 00-00-00-00 09/22/2013
SMITH PAUL / O N L I E F R M
SHMC
CHEST 1 OR 2 V IEWS F
<SOB AND FEVER R/O PNA>

3. M E D I C A L S
Inland
Imaging

4. (Auto Populating Field)
LEFT FOOT THREE VIEWS
(Auto Populating Field)
Exam description, We have to add modifier (right or left) and number of views (not images) USE ALL CAPITALS HERE

5. Pain and swelling left lateral ankle. Twisted ankle two days ago.
Good Example::
(Auto Populating Field) We usually change or add to this area. *Reimbursable: Sign and/or symptom with laterality, duration and clinical question Bad Examples: Rule-Out/Pre-Op/Pain/Space bar & period *Abnormal diagnostic exam (including laboratory results etc.), value and approximate date, if relevant, or if only reason exam is being performed Good Example: Elevated liver function tests Bad Example: LFT

6. If no priors, document NONE.
09/22/2013 St. Sam's Mt Vernon, IL
Date of most recent relevant studies with name of outside institution, if applicable.
If no priors, document NONE.

7. Check each box that applies

8. .5
Barium
Standard
Fill in if used on the exam (Fluoro or OR)

9. Any special comments noted on referral (i. e
Any special comments noted on referral (i.e. “per order please check …)
Any exam limiting factors (i.e. patient unable to lie flat, unable to hold breath)
Any other information deemed important to share with the radiologist.

10. Last box to check after everything else is done. Films checked and
Helen Murphy
HMM X
Last box to check after everything else is done. Films checked and
Exam billed!