Medtronic SureScan Pacing ICD CRT Order Form
This order form is essential for healthcare providers to confirm MRI compatibility for patients with Medtronic SureScan systems. It provides detailed instructions for assessing the patient's device status. Accurate completion helps ensure patient safety during MRI procedures.
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How do I fill this out?
To fill out this form, begin by confirming your patient’s Medtronic SureScan compatibility. Next, assess the electrical integrity of the leads and ensure pacing thresholds are within acceptable limits. Finally, complete the programming section as required.
How to fill out the Medtronic SureScan Pacing ICD CRT Order Form?
1
Verify the patient's Medtronic SureScan device and lead status.
2
Check the electrical integrity of the pacing leads.
3
Confirm that the pacing thresholds are acceptable.
4
Choose the appropriate pacing rate for the device.
5
Sign and date the form before submission.
Who needs the Medtronic SureScan Pacing ICD CRT Order Form?
1
Healthcare providers who need to verify MRI compatibility for patients.
2
Cardiologists managing patients with implanted pacemakers.
3
Radiologists requesting details for MRI procedures.
4
MRI technologists ensuring patient safety.
5
Administrators coordinating patient care and documentation.
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What are the instructions for submitting this form?
Upon completing the form, submissions can be made via fax to your local cardiology department or through direct email to the MRI scheduling team. Ensure that all patient information is included to avoid processing delays. You may also submit the form directly during the patient's visit for their MRI appointment for immediate processing.
What are the important dates for this form in 2024 and 2025?
Keep an eye out for updates regarding MRI procedures and Medtronic device compatibility guidelines as they will be updated during 2024 and 2025. Ensure timely completion of the order form ahead of scheduled MRI dates to avoid delays. Regularly check for any changes to protocols that may impact patient care.
What is the purpose of this form?
The purpose of this order form is to ensure that patients with Medtronic SureScan devices can safely undergo MRI procedures. It involves confirming device compatibility, assessing lead integrity, and setting appropriate pacing thresholds to avoid complications. This documentation is vital for maintaining patient safety and adherence to clinical protocols during imaging.
Tell me about this form and its components and fields line-by-line.
- 1. Patient Name: The full name of the patient.
- 2. DOB: Date of birth of the patient.
- 3. Device Confirmation: Checkbox for confirming device compatibility.
- 4. Lead Status: Confirmation of the electrical integrity of leads.
- 5. Pacing Threshold: Verification of the patient's pacing threshold.
- 6. Physician Signature: Signature field for the attending physician.
- 7. Physician Name: Full name of the physician who verified the form.
- 8. Date: Date of form completion.
What happens if I fail to submit this form?
Failing to submit the form may result in scheduling delays for necessary MRI procedures. It could also compromise patient safety by not adequately confirming device compatibility. Ensure that all required fields are accurately completed prior to submission.
- MRI Scheduling Delays: Inadequate completion of the form may postpone the MRI appointment.
- Compromised Patient Safety: Not confirming device compatibility can lead to unsafe MRI exposure.
- Documentation Issues: Incomplete forms can result in administrative complications.
How do I know when to use this form?
- 1. Prior MRI Evaluations: To assess device compatibility before MRI procedures.
- 2. Routine Device Checkups: Used in regular patient follow-ups to document lead conditions.
- 3. Emergency Situations: When rapid assessments are required for patients needing immediate imaging.
Frequently Asked Questions
How do I confirm my patient's device compatibility?
Ensure that your patient has a Medtronic SureScan device and check the lead status before proceeding.
What if the pacing threshold is too high?
You should assess the patient and consider contacting the cardiologist for further instructions.
Can I save my changes on PrintFriendly?
Once you finish editing, download the PDF to keep your changes.
Is there a maximum impedance range for leads?
Yes, for SureScan mode, leads must be between 200-1,500 ohms.
What if my patient has leads that are not intact?
Document the issue and consult with a cardiac specialist for guidance.
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Use the sharing options on PrintFriendly to email or share on social media.
Can I print the PDF after editing?
Yes, the edited document can be printed directly from PrintFriendly.
What happens if I forget to sign the form?
The form may not be valid without the necessary signature; ensure to sign before submission.
Is there a specific formatting required for the fields?
Fill in all fields clearly and accurately to ensure compliance.
Who should fill out this order form?
It should be completed by the healthcare provider responsible for the patient's care.
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