Iac ct scan Parameter Form This form must include information specific to the ct examination



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IAC CT Scan Parameter Form

This form must include information specific to the CT examination,

patient, and CT unit for a case study submitted for review.


CT examination performed (e.g., sinus, chest with contrast, knee, etc.):      
Patient initials (first 3 letters of last name, first 3 letters of first name) or ID (MRN):      
CT unit make and model:      
Maximum number of slices for this unit (e.g., 16, 64, etc.) or Cone Beam CT (CBCT):      

Using the table below, record the scan parameters and radiation dose specific to this case study.


Acquisition series (volume, axial, helical, delays, etc.)

     

     

     

     

     

kVp/mA and rotation time or kVp/mAs

     

     

     

     

     

Dose per acquisition, if available. The units of measurement must be indicated (mSv, mGy, etc.)

     

     

     

     

     

Dose length product (DLP), CTDI (vol) or the effective patient dose estimate for the examination. The units of measurement must be indicated (mSv, mGy, etc.)

     

     

     

     

     

Indicate the Tube current modulation or dose reduction technique used

(DoseRight, Care Dose, ASIR, etc.) if available

     

     

     

     

     

Anatomical Scan range

(dome of liver thru pubic symphysis, paranasal sinuses, etc.)

     

     

     

     

     

Increment (space between slices) (N/A for CBCT)

     

     

     

     

     

Detector collimation (mm)

     

     

     

     

     

Slice thickness (mm)

     

     

     

     

     

Pitch or table feed (N/A for CBCT)

     

     

     

     

     

Scan FOV (cm)

     

     

     

     

     

Kernel/filter

     

     

     

     

     

Reformat technique
(i.e., 3D, plane/views)


     

     

     

     

     

Contrast type/rate
(if applicable)


     

     

     

     

     




CT Scan Parameter Form

Revised 9/9/2016


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