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OVERVIEW
Once a procedure will be performed it is important to conduct a focused (yet comprehensive) chart review so that one can prepare a history and physical note and also review any information that is relevant for the procedure. While some interventional radiology procedures may seem very basic, a through chart review is still beneficial prior to conducting all procedures.
It is important to realize that some of this information does overlap with fielding the initial radiology procedure consult and the evaluation process/data collection process may not always be linear and may precede a formal chart review. It is important to also realize that this page assumes that this chart review is going to be usually performed on patients that will likely receive the radiology procedure in question.
RADIOLOGY PROCEDURE NOTE TEMPLATE
While performing your chart review for a procedure it is also useful to also begin drafting your History and Physical note that must be completed prior to the procedure. Your note should help you gather information and expedite the process of the chart review. An example of a note template is shown below that you can use:
RADIOLOGY-PROCEDURE-HP-TEMPLATE-EPIC
REVIEWING THE PATINT HISTORY
It is important to try and get a sense of the clinical context for the ordered procedure by trying to understand the patient’s past medical history to the best of your ability (while focusing on the elements that inform our understanding of peri-procedural management). It is important to acknowledge that sometimes the information below may not be readily accessible however ideally these aspects of the patient’s history would be included in one’s chart review.
WHO IS THIS PATIENT?
Basic components of a classic “one-liner” fall into this category. Patient age, sex, key diagnoses, and big picture elements of the patient’s care (recent medical events/procedures, current level of care, overall stability) are important details to bring together early on to frame the rest of the chart review/note.
It is important to also make clear what procedure is being ordered and also with what level of urgency (i.e. when is the case on the schedule?)
WHY IS THIS PROCEDURE BEING ORDERED (INDICATIONS)
This can often be evaluated in the comments section of the order for the procedure (although this is not always the case). This can be a fairly big topic, however in short it is ideal to answer for oneself “why is this procedure being ordered in this patient specifically?”. Its important to review what the indication for this procedure is (for more information on procedural indications please review this page here).
PROGRESSION OF CARE/IR INVOLVEMENT
This is a bit topic within itself however it is useful to look back and understand exactly (if you can) how this patient’s care has progressed to this prospective IR procedure. Have similar procedures been done in the past? What details are pertinent from before? Does the patient have any current IR hardware/drains/lines etc? Is there other relevant history (such as drain quality/drain output)?
CO-MORBIDIEITES
Peri-procedural management will be informed directly by a patients co-morbidities (for example patients with diabetes will benefit from a finger stick prior the start of the case if they are coming outpatient to make sure their blood sugars are well controlled peri-procedurally).
Generally speaking the following co-morbidities are useful to be aware of for peri-procedural management.
- Diabetes: can be very common cause of renal compromise in patients.
- Hypertension: very common in patients with renal disease and those volume overloaded who have not been able to get dialysis recently.
ALLERGIES
Always review patient allergies when performing your chart review. Make sure there are no allergies to medications that you will administer during the case (such as IV contrast etc).
REVIEWING THE PATIENTS MEDICATIONS
It is important to make sure you review patient medications prior to any procedure (as again this will inform per-procedure management). A patient’s medication list can also help elucidate some of their co-morbidities. It is also important to appreciate that how you evaluate these medications may change slightly based upon if the patient is presenting from the outpatient vs. the inpatient setting. Here are major categories of medications to evaluate for:
BLOOD THINNING MEDICATIONS/ANTI-COAGULANTS
Policies may change on what blood thinning/anticoagulant medications need to be held for a tunneled line however it is generally a good idea to make sure you know what the patient is taking.
ANTIBIOTICS
It is useful to be aware if the patient may have any active infection that they are currently being treated for. This can sometimes inform and alter certain management strategies (such as giving additional antibiotics peri-procedurally). In other cases procedures may be contraindicated in patients who are actively being treated for an infection.
BLOOD PRESSURE MEDICATIONS (INCLUDING PRESSORS)
The nature of these blood pressure medications can change depending upon the context (outpatient vs. inpatient) however in general it is useful to understand what medications are required to keep a patient’s medications within their current levels. This can range from blood pressure medications that lower the pressure in the outpatient setting, to medications that may be used in the ICU to keep a patient’s blood pressure elevated.
REVIEWING PATIENT VITALS
This can be easily overlooked however it is useful to routinely check patient vitals prior to procedures (as well as during/after in certain cases). It is useful to answer the following questions to contextualize things peri-procedurally.
- Is the patient febrile? A fever can be a sign of an infection and can be a contraindication or indication for certain cases.
- Is the patient tachycardic? This can be useful for various assessments but can support a picture of sepsis.
- Is the patient hypotensive? Depending on the context this can tie into a sepsis picture or one of bleeding.
- Is the patient hypertensive? Does this patient need blood presser control prior to the procedure?
- Does the patient have signs of respiratory distress? This can inform if a certain procedure is safe and/or can influence the need for anesthesia support.
FOCUSED PHYSICAL EXAM
Given the constraints of practicing interventional radiology, your physical exam will likely be deferred until meeting the patient for the first time prior to the procedure. Regardless, there are a few specific elements of the physical exam that are useful to anticipate and keep in mind.
- Inspecting sites that will be accessed: this can include the sites of drain placement, line placement, chest port incision sites, where an arterial sheath will be placed, etc.
- Evaluating current IR hardware: this refers to looking at the current IR hardware that has been placed previously (drains lines, etc). What size are they, what type? If it is a drain how much output is there? What color and quality?
- Pulse exam: especially in cases where arterial access will be gained it is important to check the pulses for where one plans to access but also more distal pulses that can become compromised (such as for femoral access the PT and DP pulses).
REVIEWING THE PATIENTS LABS
In general for most IR procedures there are a few standard labs that are commonly ordered and evaluated prior to the procedure.
Basic Metabolic Profile (BMP):
- Creatinine: this can help contextualize the patient’s renal function.
- GFR: if this calculation is present this can help evaluate if patient’s will be able to receive IV contrast (typically those with a GFR above 60 will have no contraindication to receiving IV contrast).
Complete Blood Count (CBC):
- Hemoglobin level: not really used in IR procedure guidelines but can demonstrate how much margin the patient has for blood loss before requiring a transfusion.
- White count: if elevated can serve as a sign of infection (which can either be an indication or contraindication for certain procedures, i.e. line placement vs. fluid collection drainage).
- Platelet count: the amount of platelets can serve to be a contraindication for certain procedures if the risk of bleeding is high enough.
Coagulation Labs:
- INR: the patient’s INR is also used as a guideline for assessing bleeding risk prior to a procedure.
Other Labs:
- Liver function tests: in certain cases liver function tests (including bilirubin) might be relevant and be important to follow.
REVIEWING RELEVANT PRIOR IMAGING
This is an incredibly large topic however is a very important step prior to any procedure (provided the patient has any prior imaging that is accessible). Given the size of this topic it is covered in more detail on a separate page here:
Fundamental Procedural Radiology Peri-Procedural Tasks: Reviewing Relevant Prior Imaging.
With this in mind some of the basics are summarized below. While the nature of this portion of the chart review will depend entirely on the prospective procedure, there are a few things to keep in mind when reviewing imaging:
- What happened during prior radiology procedures? Looking back to a prior radiology procedure (and its imaging) can be helpful in many cases (provided it is a relevant procedure). What was done in the past? Any special equipment used? Any relevant findings that changed the nature of the case?
- What is the vascular path to the area of interest? This refers to intravascular work, but it is very useful to trace the vascular path all the way from the access point to the area of interest. Is the access point actually accessible? Does the patient have variant anatomy? Are there landmarks for finding certain vessels?
- What is the window to access the target? This refers more to extravascular work such as a fluid collection drainage. How will the target be accessed? Will this change positioning of the patient?
ASSESSMENT/SUMMARIZING SAFETY CONCERNS
This is am important component of fielding the consult for a radiology procedure however also is a core element of performing a complete chart review. Once you have reviewed everything in the patient’s chart it is important to summarize if the patient has any of the following safety concerns and overall if they are a good candidate for the procedure. Here are some things to answer:
- Does the patient have a clear indication for the requested procedure?
- Does the patient have any relative or absolute contra-indications for the requested procedure?
- Is the patient hemodynamically stable?
- Is the patient’s respiratory status stable?
- Is the patient high risk for aspiration?
- Is the patient high risk for an allergic reaction?
- Is the patient high risk for bleeding?
- Is the patient high risk for infection?
- Is the patient high risk for for renal injury?
PLAN/ADRESSING SAFETY CONCERNS
Based upon the risk assessment above a clear plan should be put in place to address important aspects of peri-procedure management as well as measures that will be taken to minimize risks to the patient. Aspects to include in the plan (if appropriate) include:
- Diagnostic workup that is still required (labs, imaging, etc)
- Sedation plan
- Anesthesia’s role in the case (either for sedation or for patient stability in higher risk cases).
- Diet plan (when to make patient NPO)
- Premedication for allergic reactions
- Administration of blood products
- Anticoagulation plan (both pre and post procedure, specifically medication timelines).
- Antibiotic plan (both pre and post procedure, specifically medication timelines).
Page Updated: 04.14.19