An Old Requisition, a New Fall, and an Employer's Request
A 44-year-old warehouse worker arrives at an outpatient imaging department with a requisition for a lumbar spine series. The order is dated seven months ago, is signed by an urgent care physician for "low back pain," and contains no other clinical information. The patient says he fell at work three days ago and the pain is now much worse and radiates into his left leg. The physician who signed the order has left the practice, and the urgent care clinic says it cannot issue a new order without seeing him. The patient's employer has faxed a request for the images and report "for fitness-for-duty purposes," and the patient mentions he has been placed on light duty. Facility policy requires a current order with a clinical indication before an outpatient exam, and state law allows radiographers to perform only examinations ordered by a licensed practitioner. The patient asks you, "Just tell me if anything's broken - I can't afford another visit." The radiologist is on-site.
1. Can you perform the examination on this requisition? What are your options?
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No. The order is seven months old, lacks a current indication, and the clinical facts have changed: a fall with radiating leg pain. The examination that is appropriate now may not be a routine lumbar spine; it may need to include the pelvis, or the patient may need urgent assessment for fracture or for red flags such as saddle anaesthesia, bowel or bladder changes, or progressive weakness. The signing physician has left, so the order cannot be verified.
Options:
- Call the radiologist, who may be able to issue a verbal order with an indication, read back and documented, and countersigned per policy, or may direct the patient to the ED.
- Have the patient seen at urgent care or by his own physician for a fresh order.
- If red flags are present, send him to the ED immediately.
Do not perform the examination, and do not "upgrade" the old order yourself. The order is the legal basis for the exposure and for the examination performed.
2. How do you handle the employer's request and the patient's request for an interpretation?
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Employer. Nothing is released without a signed patient authorisation that meets HIPAA or the applicable privacy law. A fitness-for-duty request is not a radiology request, and even with authorisation only what the authorisation permits may be released. Fitness for duty is an occupational-health determination, not a radiographer's judgment.
Patient. You cannot interpret the images. Explain that the radiologist's report goes to the ordering provider and that he can request his own records through the release-of-information process. Say it kindly and without hinting at findings; "I'm not able to read it for you, but the radiologist will" is enough.
Confidentiality also means not discussing him in public areas or with co-workers who are not involved in his care. Keep the requisition, the fax and any conversation about the employer's request factual and documented.
3. If he becomes angry and threatens to go elsewhere, what do you do? What if the radiologist offers a verbal order?
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Stay calm and professional. Do not perform an unordered examination because he is angry. Explain the reason in plain language, offer to call the radiologist or help him obtain a same-day order, and give him the options. If he chooses to leave, document that he left without service and why.
Verbal order. If the radiologist gives a verbal order with a clinical indication, that is acceptable under policy: record the indication, read it back, and have it countersigned. The order must reflect the current presentation, not simply repeat "low back pain" from seven months ago.
Scope. A radiographer performs the ordered examination and produces quality images. Diagnosing, advising on treatment, or telling the patient whether something is broken is outside that scope, and it exposes the patient and the department to harm.