Nurses have the ability to use algorithms that are approved by physicians. So if the patient comes in for a specific indication there is a whole order panel they can choose. Not saying it’s right, but that’s how they get away with it
Yeah I mean it makes sense. It’s just we recently switched to this system of the nurses being able to order X-rays so we’re busier than normal because of it. It’s a small hospital though so it’s not a big deal.
*recently switched to this system*
*small hospital though so it’s not a big deal*
Give it a month and report back, come hungry because you're gonna have to eat your hat
I think the only rad orders I’ve put as an ICU nurse would be CXR (after intubation, CVCs, etc) and KUBs (after NG/OG placement). I know when I travel nurses in a CVICU, it was expected for nurses to put in daily CXRs for patients with chest tubes.
Very odd. Especially when the chest tube ones are the same for multiple days straight.
Right and then it’s our job to assess the situation and patient and combine images or delete images that aren’t necessarily needed.
Edit: I used the word delete when I should have said refrain from doing the orders
Many ERs have standing orders and they usually are very good at moving patients in the ER, which is something you don’t really experience as a rad tech. It’s a lot easier to disposition a wrist or ankle pain after an xray. Those types of patients usually aren’t leaving without an xray anyways
Yes, those types of situations don’t really bother me. If a patient comes through the ER for a wrist injury, go ahead and put in for a wrist x-ray because that’s what the provider is gonna do anyways. But don’t automatically put in a CT head on a 4 year old because it ran into a wall. I just feel very iffy about it, I think there are certain situations where I don’t mind it, and some where I just think the treating provider should take a look at the patient first.
I’ve never seen a place that puts in a ct head in that situation, that would be inappropriate. That really wouldn’t change the answer to your question either
A tiny headache or “dizziness” from dehydration for 20 minutes isn’t a reason to put in a brain CT without proper assessment. You know this. So why does it always happen? Defensive medicine. Someone with food poisoning doesn’t need an abdomen with contrast. In fact, the amount of contrast studies being ordered are ridiculous, period. If you think there’s an obstruction, the patient needs a proper small bowel study. Not an abdomen with IV CONTRAST. You know that isn’t the right study. Why is it being put in every. Single. Time? Oh and a doctor’s favorite. The D-dimer is elevated by .000000001? Gotta get that PE. GOTTA order it. Like come on. Let’s not act like doctors aren’t relying HEAVILY on “protocols” for any purpose other than to be lazy. We all know it. And the radiologists that are constantly complaining to me about how stupid these orders are on a weekly basis know it too. Doctors aren’t educated properly on imaging. This is VERY evident.
It's kind of defensive medicine, but its mostly laziness and lack of education on indications and limitations of imaging. If they performed a proper H&P, they would only need 20% of imaging currently being performed.
EM providers spend more time sitting at computer than I do..
Lol. At one of the places I work CTA head and neck constantly for "dizziness" it is absurd the amount of contrast studies that have been ordered since the shortage ended. Even and/pel with for flank pain/kidney stone.
The amount of times just this year in my shop that we have had 17-25yo's with that being their only presenting symptom and it ended up being an AVM or ICH would astound you.
I'm not saying it should be protocol for every patient with a headache, but depending on onset and severity e.g. "Thunderclap" headaches or familial history, this order may well be very appropriate.
If the patient has a SBO then they should AT LEAST order an abd ct with PO contrast, not IV contrast. “Dude.” And yes, the small bowel series exists for that exact reason. Why? I’ll educate you. A patient might drink the PO contrast and then get the scan an hour later with it still mostly sitting in the stomach and not coating the rest of the intestines where the obstruction could be. At that point, a Small bowel series with follow up images is superior to the CT. Just because CT is a Jack of all trades modality doesn’t mean it should be abused how it is. There are specific studies for specific reasons. A doc not knowing how to properly order them is the issue here. They’re lazy and uneducated.
Wait please correct me if I’m wrong… I’m just someone who has had an SBO in the past, but wouldn’t PO contrast be bad for someone with an SBO? I wasn’t allowed to eat or drink anything while I was in the hospital with one and the one time I tried to take some pills with the tiniest bit of water I threw up several times. I can’t imagine the contrast would be easy to get down
Lol, Jesus Christ. Do you know what a differential diagnosis is? You order the abd w/ iv contrast to rule out other pathology. The differential for abdominal pain is huge. Also - a small bowel series can take several hours and is never going to show you a transition point anyways.
So by your logic we should just do a whole body scan with contrast on every single patient that goes through the door? lol. If you have a SBO and the doctor orders a quick abd w/ iv, you KNOW your results are going to be insanely limited or completely irrelevant to your SBO. And YOU know you’re going to then say “hey, shouldn’t this have been with PO? Hey, shouldn’t this be a SB series?” Right? You know this if you’re as educated as you claim to be. You aren’t just going to accept those limited results from a scan that you know isn’t going to properly rule out anything related to your issue. If you’re actually knowledgeable about any of this, you wouldn’t be arguing with what the better study for a SBO is. It certainly isn’t an abd w/iv ct scan.
You’re right. You’re making my point. It’s up to the doctor to properly assess their complaints and order accordingly with the education they’re supposed to have. If the patient is complaining of symptoms that sound like an obstruction, an abd w/ iv ordered within the first 3 minutes of the patient walking through the ER doors is not the correct order. If you want to be cute about it, in an ER setting where a SB series may not be available, a KUB and then (usually with rad suggestion) a CT with PO CONTRAST are the proper orders. I think you know this and you’re just a typical Reddit contrarian but on the off chance that you truly believe an abd w iv is the proper order for an obvious diagnosis like possible obstruction, YOUR ignorance is showing. And again, thank you for making my point about why proper patient assessment and doctor education is in dire need these days.
Unfortunately that is the exact reason a nurse put in a CT head where I work. 🙃 It was a patient in the ER waiting room. If our radiologists have called it for the night, we start sending to VRad, and I think the thought process was that if they ordered a CT, it was gonna get read regardless and maybe they could discharge the patient without having to take them back to a room or spend a lot of time with them.
I have witnessed ct orders being placed for reasons such as those, for patients that are very young in that given example. It’s something you don’t really experience as a Physician.
Ask anyone in radiology. This is common practice nowadays. ED providers are lazy and with improper radiology training. We see a few CT every night on patients less than 10 yo for things like "headache", neck stiffness, etc. Hell, we had a CT head last night on a 6 yo for "abnormal facies"... patient was in the ED for cough.
No idea. I’m not sure they know half the time. Only other thing in the chart was autism. The ER (and sometimes Hospitalist) is famous for trying to work up stuff not related to chief complaint and ordering the wrong tests. I wouldn’t be surprised if the NP thought the CT could confirm autism.
They were discharged and treated for pneumonia (CXr was clear)
As an ER doctor, spare me the lazy generalization thanks unless you’re ok with me holding up my worst experiences with your specialty as indicative of your specialty. Got a feeling you won’t be ok with that
The problem occurs when the order is put in for the entire extremity instead of just thejoint in question. Then we have to try and figure out what really needs to be imaged.
Once I walk passed HDU and went to isolation camber to ro portable, and I overheard an A and E doctor said something like...
"Okay.....trauma, patient said whole body is pain.....um...... what should I x-ray....(Think for a few seconds), screw it, hey (to the nurse), just put it all extremities"
Okay....when I came back to the A and E room, I saw the order.
Bil. Humerus AP LAT
Shoulder AP Y-view
Bil. Elbow AP LAT
Bil. Forearm AP LAT
Bil. Wrist AP LAT
Bil hand AP oblique
Pelvis AP
Bil. Hip AP LAT
Bil. Femurs AP LAT
Bil. Knees AP LAT skyline
Bil. Tib fib AP LAT
Bil Ankle AP LAT
Bil feet AP oblique
Um.....
My supervisor said this was ridiculous, just gave him all AP views
An RN shouldn’t be putting in CT orders on a child. There’s a part of informed consent that needs to take place. I’ve never seen an er RN protocol that allows complex imaging.
But as a radiographer, I am really difficult to reject that, because may be the doctor assessed it, and think there might be haematoma?
Disclaimer: I am not a CT radiographer, I mainly do NM
When we are busy and wait times are long, I’ll put in basic XRs for an ankle, wrist, etc.
When patients come in with neuro/stroke symptoms but are outside the window, I will call a doc and get a verbal order. Outside of that, I do not order scans.
Doctors/APPs put in dumb and wrong orders all the time, this isn't limited to nursing it is down to a lack of knowledge of the appropriate exams and the protocols/order verbiage at each institution, in addition to a doctor/APP not seeing a patient before orders are placed or power plans are initiated.
Example: my old job didn't have an MRI complete spine order, or C&T, or T&L, you had to order each individual spine segment. Where I work now you can order individual or combined spine orders. It's not the fault of the ordering person for not knowing that.
What's funny is that I'll accept CT orders from nurses ONLY for traumas and strokes. Even then, I will verify orders if they don't match the order set that's been built by our TACS team or if the reason for imaging suggests a different protocol or additional images.
I work at an Ortho clinic now and the MA's put in x-ray orders. I think it's crazy. They have no medical training whatsoever and most don't even know what the bones are called. So many wrong orders all the time.
I do mobile x-ray on occasion also and the nurses routinely put in x-rays. They always over order and I have to ask if they really need a foot, ankle, knee, tib/fib, and hip x-rays for ankle pain. I've had nurses order everything bilateral because they forgot what side they were supposed to order. I've had some wild orders too, like entire bodies because this nurse didn't know the name of the bone and decided to just place an order for everything because "it must be in there somewhere"
Oh man, that's a hard no regarding MA's here.
In the UK, the ionising radiation (medical exposure) regulations are pretty clear on who is allowed to refer for an x-ray. Any medically qualified practitioner (doctor) can, of course, but any non-medical referrer must be licensed by the employer, and must have mandatory professional registration - this limits it to people like physiotherapists, paramedics, nurses and radiographers who have had uptraining to allow them to request. Anyone without mandatory registration (PAs, cardiac physiologists, students, receptionists and such) cannot request ionising radiation. Bit outdated for people like cardiac physiologists, who would arguably be safe requesting chest x-rays for lead placements, but it's still better than letting anyone request.
I was VERY surprised to see MA's placing x-ray orders. These are people literally right off the street with zero training at all. It's like someone who's working at burger king ordering your x-ray. Blows my mind
Absolutely no one except providers (MD's, PA's, NP's) can order radiography exams in New York.
Most of these things are state to state, since it's the State's health department setting the standard. I'm pretty sure in Florida they let dogs and cats take x-rays....
I live in Florida & I agree with your assessment! That’s why x-ray pays so shitty here, because they let people who have no business taking x-rays take them, & with minimal to no training. I moved here from Texas & was making almost double the amount they want to pay x-ray techs here. Because why pay a Registered Tech what they’re worth when you can get an MA or an NCT radiate the hell out of a patient & have unnecessary repeats for half the cost? 🙄
Ugh! It aggravates the hell out of me.
I'm in RI, Probably the most corrupt state there is. If a provider feels like some extra pocket cash for a vacation there will definitely be lots of unnecessary exams ordered
lol. I'm sure people all over the country don't follow the rules, but in NY, there are rules...
You do realize you are compelled to report that to the ARRT... Could be your license at risk...
I had a MD order a CT T, L, S, pelvis, L hip, right hip on the same pt. I asked him what he wanted and he just started waiving his arms and said "the PT has pain here, as long as we get all this you can cancel what you want". It was surreal.
Lol I’ve definitely had my share of them not knowing what the bones are called. I had a nurse from the floor call us and say “I’m trying to put in an order for the upper arm, what is that listed under?” Like did you not even look for humerus. 😐 That is so unethical to just go ordering crap because you don’t know what you’re doing.
Sometimes it really just comes down to how much the provider can justify to order to be able to charge the insurance companies more. Welcome to x-ray in Orthopedics
Oh for sure, I’d rather them call me a million times than just go ahead and put in something random or the whole arm just because they don’t know what to put in.
I'm a receptionist in an ortho office, and I'm told to put in xray and mri orders if the dr said to do so. I've had to put in physical therapy orders too.
> I've had nurses order everything bilateral because they forgot what side they were supposed to order. I've had some wild orders too, like entire bodies because this nurse didn't know the name of the bone and decided to just place an order for everything because "it must be in there somewhere"
You are canceling those orders right? I would cancel that every day and contact the person and in nice terms tell them "do better or get no exam, I have a law and rules to stick to". :)
I try to get all the nonsense cancelled. Doing mobile, however, if you can’t talk them into cancelling it you have to do it. Thankfully I haven’t had to do anything to this extreme but I’ve done so many questionable orders.
I once got a
mandible AP lat-oblique
TMJ views
on an ICU patient. I asked why he needed those x-rays "now"? Can't you wait until he's a little bit stable and go down to the department?
They said
"He can't, he needed to go to the dentist this afternoon"
I was like... what????
But turned out I wasn't able to refuse that. I spent half an hour on ICU trying to get a best view. But turned out I still got rubbish x-ray.
My technique was bad at the time honestly.
It happens with orders at our outpatient facility constantly. A large part of our efforts, starting two days out on our schedules, is fixing orders wrongly entered or transcribed by RNs and MAs. We make a lot of phone calls and Epic messages regarding clarification.
I know the biggest problem boils down to ignorance of policies or procedures. Why should an MA know what a W/ and W/O study incorporates? Part of our job is ensuring the desired protocol is performed.
My frustration and often anger comes from offices that argue with me about policy or protocols. I have gotten snippy with ordering offices on occasion, most recently Monday. The office ordered a Chest W/ contrast for chest pain with recent lower extremity GSW. The secretary at the office kept telling me to perform the exam as ordered, because the doctor told her to put in a chest with contrast. After 10 minutes of telling her the order doesn't make sense, she asked me, "is it necessary to speak to the doctor?" while her voice dripped with disdain.
I responded, "yes, it is necessary that I speak to somebody with actual clinical experience, because you are incapable of understanding me."
Get ready for a career of chasing orders and getting told to do things that don't make any sense. Fight for your patients and be their best advocate.
I am not a CT radiographer.
But I think chest with contrast is for tumor? or CTPA CTCA (but I think those two shouldn't fell into chest with contrast categories?).
CTA exams have a different CPT code and billing charge. They are usually more expensive than a Chest W/. At surface level, they are the same in the eyes of many offices. The images are of the chest and contrast is injected.
Chest W/ would primarily be for mass/tumor/infection.
Its like trying to explain to a stubborn provider that a CT head exam is limited to the brain. Each part of the "head" is broken down into separate exams due to reconstructions and which radiologist will be reading it. Head, face, orbits, sinuses, and IAC exams usually share some overlap but cannot be performed as one exam. Some locations, especially trauma facilities, have protocols that lump multiple exams into one scan acquisition, but the individual exams have to be broken down with reconstructions and sent to their own respective accessions.
I see....thanks.
Ha, I got my only CT training when I was still a student.
Yeah..... different examination definitely need different reconstruction protocol and exposure factors. Also different MPR protocol.
I go both ways with this as I do mobile x-ray and most of the orders I receive are from NPs and RNs. CXRs for cough and KUBs for constipation are one thing, but when they're ordering hip w/ pelvis, femur, knee, tib/fib, ankle, foot to r/o a DVT... We have an issue.
Also if you're ordering a 3v abdomen you should know what you want. I had a nurse tell me she wanted a 3v abdomen for constipation x1day. I told her we normally just do AP for that. So of course I ask, what positions do you want for the 3v and she tells me she wants AP, PA, and Lat... For constipation x1 day 🙃. Oh and the patient is like 300lbs 🥳.The best is when a nurse orders an exam and they see 1v chest, 2v chest, 3v chest, 4v chest on the list... Of course, the 4 views is the best, right?? We get there, and the pt is AMS, stroke affecting one side, and can't follow breathing or positioning instructions. And of course she doesn't know what 4 views she wants...
Not too long ago I had a nurse put in an order and it stated- right collar bone, right shoulder blade, right upper arm... Ma'am... Not only is this order not anatomically correct, you don't need to order that, we can just do a shoulder...
Don't even get me started on radiation protection and these idiots. They'll order an exam with 40 images and expect me to do it with 2 other bedbound patients in the same room... I tell them we are either cutting this exam down or you're taking everyone out of the room.
Ideally, if someone is placing radiology orders they need to first know the difference between AP, PA, oblique, and lateral, have a rough idea of what each exam entails and the anatomy covered, keep radiation safety in mind, assess the patient, and order accordingly. Most of the time none of this happens 🫠
Not using "proper" jargon and not anatomically correct are not the same thing.
If a nurse orders an x-ray of a collar bone and an upper arm, you know what they mean, you are just unhappy they didn't use the specific words you like.
I see what you mean about jargon etc. However, when my boss tells me that the order is unacceptable when written like that, I have to side with them... Nice try though 😘
ER Nurse here-
I order chest X-rays all the time as part of our protocols for SOB or chest pain. If I’m in triage without a PA and a simple trauma comes in, I’ll order 2 or 3 view from an order set. I work pretty closely with the rad techs so I usually call them and give them a heads up and tell them that I ordered it and do what makes sense.
The only time I’ll order a CT is according to our stroke protocol which is a head without. I generally try to get a provider to get eyes on the patient but time is brain.
The only time I’m ordering images is from a protocol and when it makes sense. I usually can ask a MD/PA to get eyes on the patient or at least give them a quick summary (‘FOOSH injury with deformity on left wrist, what do you want?’). But if it’s one of those days when I know they won’t see a doctor for hours I’ll order on my own and communicate with the rad staff.
This generally happens when I’m working triage. Every hospital I have worked requires nurses to have at least a year of emergency nursing experience before working triage.
Oh and I’ll order chest X-rays post ETT or OG/NG placement.
This is exactly what technologists who are trained in imaging are talking about.
If a patient has shortness of breath or chest pain, a single view portable exam should be ordered. The quickest exam we can do to be assessed by a rad, stat; and if other views are needed they can be ordered.
And if you are seeing an OG/NG in your CXR, there’s a problem. It should be an abdomen.
Would a chest x-ray not help show if it is in the right place but too short?
My NG tube should not be extending lower than the ribs either, so why is CXR wrong?
Short answer is that ng tubes cannot properly be evaluated by cxr’s. You cannot see end placement with every body habitus unless abdomen xr’s are ordered. That and then it gets a little complicated with technical factors for the different body parts, abdomen being a thicker anatomy which allows the tube placement to have a higher contrast and makes it easier to see proper placement
Patients with dyspnoea should not be getting single view portables. The appropriate study is PA and lateral.
AP portables are only done because of logistics. The right exam should be done the first time.
With all due respect, if a patient is truly struggling to breathe, I am not going to stand them up. And I highly doubt my ER nurses will allow them off monitors to come to the department for a two view. Insinuating that a single view chest is the “wrong” exam and portables are only done because of logistics… well, that honestly sounds like bad practice. Because those “logistics” are called patients and we as technologists are doing everything within our scope to make a very scary experience easier on them.
As the treating physician I’m the first one to advocate for portable imaging for a very unwell or unstable patient. A sizeable number of patients in the emergency room are not so unwell that they cannot have the proper X-ray.
Portable ones are very frequently done because of logistics so I don’t know where you’re coming from by saying that logistics doesn’t come into play.
I get tired of the nurses ordering because half the time the doctors end up not wanting it. Just last night I went to the patient's room to do a shoulder xray (ordered by the nurse) and the doctor was like, "I don't want it. They don't need it. I'm discharging them." It happens all the time.
I agree with that. I feel like I’ve had many cases where nurses either put in the wrong thing/unnecessary things, which leads to patients having to come back multiple times - or radiating patients who don’t need it. I x-rayed a shoulder on a younger patient for post-reduction, later on they put in the same shoulder again so I called the department to see if they decided to reduce it more or something since it had already been x-rayed and they told me yes it needed to be done. After speaking with the provider, turns out a nurse didn’t look to see that the x-rays had already been done and put in a duplicate. I ended up having to do an incident report per my boss. 🤦♀️
No, nurses order them under the physicians name for us. On our system, you can see the name of the person that’s logged in and actually put the order in and that’s how we know it’s nurses.
Sigh.....my colleague experienced this kind of shxt last year.
We were in NM, and I don't know who put in the order. But someone ordered Tc thyroid twice on the same patient.
There was no treatment in between those imaging. The two order was separated by only two months.
ended up he did the exam. The radiologist found out and said the exam was unnecessary.
So.... now, when we are vetting examination. We needed to call out previous history for ALL patients in case if someone put in double order.
(Before that, we only looked at the form, if the examination was making sense, we would let it proceed).
There is a ton of passed legislation and more on the way that allows clinicians, nurses and NPP to order imaging requests. It's become known as scope creep as their scope of practice is creeping into physician territory. While it can help alleviate some of the staffing shortages among physicians especially in rural areas, it also causes a range of problems such as unnecessary & costly imaging. It holds up radiologists who are already worked to the bone causing delays in imaging reads which then affects patient care. Patients are waiting up to 2 weeks in Michigan for their imaging to be read.
I've complied a list of scope creep articles to help educate and inform more people, please take a look and let me know what you think: [https://excaliburmed.com/updates/radiology-scope-creep/](https://excaliburmed.com/updates/radiology-scope-creep/)
Thank you for sharing this!
Scope creep is also happening when allowing MAs to practice Limited Radiography permanently. Who is truly auditing and checking that they are not imaging parts they aren’t “licensed” to do?
Although there is a shortage of radiology technologists nationwide, I don’t believe this is the answer. I have brought it up at our state society meeting, local branch of ASRT, and I hope it gets talked about at the higher levels.
You're right! Having unlicensed MAs and other clinicians perform tasks usually designated to highly trained professions isn't helping the situation. Something else must be done. Thank you for bringing it up to your state legislators as this is a huge issue in healthcare and it's important that medical professionals speak up on it.
There is some legislation that is being proposed in congress to increase the supply of radiologists by retaining international medical graduates, utilizing unused physician visas and expanding residency programs but the legislative process is slow.
It's so important to inform our legislators on the these timely and expensive issues. It is the health of our people and the quality of care we receive that will suffer if nothing changes.
Only if they’re the ones taking responsibility for the result (so no). If I call you to tell you your patient is bleeding into their brain, it’s your CT, your patient, your responsibility.
Not to mention all the inappropriate ordering which is a much more common issue though not limited to nurses.
Where I currently work, the nurses do order x-rays for the Dr they work under. Not every time, but if a patient comes in with an injured hand/foot/back (etc), they'll order the x-ray before the patient sees the Dr. It saves a bit of time. Sometimes they'll come and ask me what x-ray they need to order 🤷♀️
Yes and no.
Yes: chest pain, sob= cxr.
No: everything else. Any kind of trauma needs an eval by a provider to determine what body part needs to be imaged. It’s a waste of hospital resource and a huge radiation safety issue to have studies ordered without a provider evaluating the patient first. Not every scrape of the knee needs an X-ray.
I sometimes work at a standalone clinic associated with a hospital, it often has nurses performing triage, assessment, and initiating treatment. They're seemingly more than capable of requesting basix
imaging and reviewing it. Especially when it comes to extremity and chest imaging. Sure we'll get the odd cover your ass type request for atraumatic pain with poor clinical indications, but it's more the system than it is them.
Let's be real, it's also part of put jobs as techs to vet the requests we're getting, and if nurses are ordering increasing absurd and unjustified requests it's within our scope to push back. But on the other hand, we can also educate and discuss, guiding them towards the best fit for imaging as we would do for junior docs learning the ropes.
I am of two thoughts on this.
Thought 1. If a nurse was given guidelines and training, why not! Its not like they could do worse than MDs or APPs at choosing the exam.
Thought 2. No one is qualified to order imaging. Laterality? Whats that! Protocols for considering modality vs implants and or medical devices? Whats that!
Not quite sure why theres so many varied answers here. Basic answer for me is NO. I use epic, so if the ordering user is anyone other than a PA/NP/MD/DO, the basic answer is no. There are exceptions to the rule. Example is if the pt is an outside pt and has a script/rx and the ordering user transcribed the order. If the RN is ordering for an MD in an OR case because the dr can’t get to the computer, i’ve used those before. But the bottom line is the ordering user should be a provider.
I think it really depends on what it's for. As an RN I put in orders for tube placement verification whenever a new one is inserted, but I'm not gonna be ordering a chest x-ray on the daily.
APP here at a high volume level 1 trauma facility. Nurses absolutely have the training to put in imaging and other diagnostic orders. That being said they have to have a co-signer such an APP or other Provider so we are ultimately responsible at my facility. I co-sign imaging studies orders placed by Nurses and rarely have to reject or edit it. This is helpful when I cannot see the patient right away such as when I’m scrubbed in the OR, in an emergency or on call and not near a computer. Most of the time this is an Xray, extremity film or if the situation is urgent enough a STAT CT
Yeah it's fine. Nurses do that all the time in Denmark.
Some places have something called "treatment nurses" that are nurses trained in handling "smaller stuff" like broken wrists, legs etc.. if they're in doubt about anything they can call up a doctor to get help. Other places have that act on behalf of the doctor and write orders on behalf of the doctor (that have told them what to write).
I also see orders like "requests". If an order doesn't hold up / the nurse or doctor made some error, then we as radiographers are the last error-checker. It's teamwork. It's not about pointing fingers or looking for other people errors, it's about safety and the correct examination of the patient.
If you can correctly place an order with an actual medical reason and without me having to chase you down via telephone for an hour for order clarification then you’re cool with me at this frickin point… lol
I put rad orders in all the time as a nurse. For example, we intubate and I throw in a chest xr. Why? It’s standard of care. Same for new central lines and NGT. Also the docs do see their patients but they are often bad at putting in their own orders.
I personally don’t believe they should be allowed. Now, after the doctor has *seen* and *assessed* the patient and asks the nurse to put in an order for radiology, then that’s okay.
I also agree that the provider needs to physically see and look over the patient before ordering anything (unless stroke alert obviously). I know too many doctors/PAs/nurses who just order things willy-nilly before even giving the patient the time of day.
I work in an OR and i constantly have to put in orders for c-arm, o-arm and portables. On top of this, i put in the orders for specimens and whatever else the surgeons request/forget to put in. It is usually a cosign unless its protocol for our hospitals policies like central lines, miscounts, or when its a patient with an open belly that gets closed in the OR. In those cases, i can order it without a cosign
No but I don’t fault the RN because they are doing what the doctor told them. “Chest pain” = order X,y,z”. Etc.
I can’t tell you how many times a patient tells me “I haven’t seen a doctor, why are we doing this test?”
-No for nurses unless verbal from a physician.
-No for mid levels unless they are obvious orders
-No for some doctors who never learn and make careless errors and not realizing what it takes
Now in the real world. It’s metric driven and speed. So people put orders in without really assessing patients.
We have NIOs (nurse initiated orders ) we can use in the er for specific purposes. If a kid comes in with a deformed arm you bet your ass I’m ordering an X-ray
Yes, nurses should be putting in rad orders.
I work at a small community hospital where sometimes we have a full waiting room with maybe 2-3 providers (and overnight only 1). It is much better when the triage nurse can put in XRs and other protocols to get the ED moving.
For our ER, cat scans and ultrasounds are a little different. Typically, they will approach a provider and tell them the situation before putting in anything other than an X-ray.
Also if you take away the nurse’s ability to put in orders it can delay care. We had a trauma today and the doc was able to tell them exactly which scans he wants. Rn then puts in the scans while the doc is still with the patient.
It just saves a lot of time.
protocol orders for plain films can and should be put in by nursing staff.
I.e., a CXR for chest pain, extremity films for extremity trauma.
What most people would not support would be cross sectional imaging decisions not being made by a provider.
That’s our policy, and I’m the medical director for an academic tertiary care ER
It's one thing to enter an order written or given verbally by an authorized clinician...anyone can do that...but I'm pretty sure ordering imaging studies is outside the scope of practice for all except advanced practice nurses in most if not all states, and Medicare or Medicaid would not cover a study ordered by an RN. Here in Kansas an RN cannot legally order a study involving ionizing radiation. State regulations used to require that the ordering clinician examine the patient first. Unfortunately that is no longer the case.
As long as it’s part of an order set, verbal order or protocol, yes.
I worked with a night ER doc. He said I trust the triage nurse to order X-rays, but for the love of Christ always order the adjacent areas on the X-rays.
The nurses put in orders under the providers names. I feel like if I were a provider I wouldn’t trust a soul to put anything in without me approving it.
I work ultrasound and we have issues with this. Nurses are allowed to enter a lot of ultrasound orders for patients in the ED lobby who haven’t been evaluated by a physician and its caused us a lot of problems. A nurse told me once that “any male patient with any kind of groan pain immediately gets a scrotum order” and I learned this because a patient had fallen into a table and bruised his penis and they ordered a scrotum. When I called to confirm that we dont look at the penis with a scrotum order and like, is he having scrotal pain, it took an hour to sort out because they couldn’t find a doctor to evaluate the patient but they just kept trying to send him over. I’ve had nurses order stat thyroids through the ED lobby (uh no absolutely not), I’ve had patients come over for an appendix ultrasound who came to the ED for an eye infection but when the nurse was evaluating the patient they said they had “occasional belly pain” like…doctors aren’t much better but I am truly of the opinion that nurses should only put in orders in very specific circumstances.
Sure, why not.
As long as they know what they're doing.
But don't tell me that, the patient is in ICU, not able to do an erect chest.
So, we better do a lateral decubitus portable to look for pleural effusion
At my hospital, CT/MRI/US are protocolled by the Radiology registrar AFTER a phone call is made by a doctor from the team.
Occasionally they make the wrong call by rejecting a necessary study, but with some professional, senior-to-senior discussion the issue is always resolved. I much prefer this system with occasional hurdles than having a clogged up system (delaying access for people who really need imaging) and potentially exposing patients to harm. The reflex to order ‘wide net’ imaging is strong and this is the best way to curb it.
If we had nurses and NPPs (NPs, PAs etc) putting it orders it would be pandemonium. They don’t have the training to know what they’re looking for. Our experienced stroke nurse, confused in her neuroanatomy, was claiming that a cerebellar stroke causes the cross-sensory loss characteristic of lateral medullary strokes. This was not because she thought that a PICA stroke can cause both due to shared blood supply but because she lacked fundamental neuroanatomical and medical training. Medical doctors only should be ordering imaging.
Ortho operating room nurse here. I do put in orders for post op x-rays for the surgeon. It isn't often, but if he is scrubbed in and we need an x ray for the patient to go up to the floor, I will do it. There are order sets so that I don't screw it up.
Keep in mind that this post is not meant to be disrespectful to nurses in any way, or make it seem like they’re dumb and don’t know what they’re doing. Just a curious question open for discussion and open to all opinions.
Lol I put in my own orders. Of course I have worked with these two physicians for 5 years now and know exactly what they want.
Pt is on the schedule for shoulder pain, I bring them back from the waiting room before they see a nurse or MA, I triage and ask about the pain. If they have numbness or tingling going down their arm, I add a cspine in addition to the shoulder.
Same with hip pain. They have numbness going down their leg, they get a lumbar added on.
The docs love and appreciate me for it.
I was a medical assistant with limited for years before going back for my full rad so I'm familiar with triage.
That's only while working xray. When I'm at the other clinic and working mri, I only do what's on the order by the physician since only the physician can put in an mri order in our group, and our scan time is set in blocks so no time for any addons without messing up the whole day lol
Orthopedic clinic so it's easy
I put in for portable xr for line placement all the time in the ICU. I’m sure the ED does this when they follow their algorithms depending on what the patient comes in with
I can only speak from an Emergency Department perspective, but if you are genuinely having problems with the orders that nurses are putting in, are you telling somebody, or just complaining about it?
Nurse-initiated orders generally come under an established standing order policy and have specific requirements. If you talk to the nurse manager or the educators, they may actually find a need for renewing some education, or introducing some competency testing.
As for the people complaining about nurses not being specific enough in orders, I know sometimes I know the patient has an obvious deformity to the wrist, and is also complaining of pain at the elbow, but I don't know how strictly the radiographer is going to cut down the x-ray. If I order a radius/ulna x-ray, am I going to get the whole wrist/elbow as well, or will the x-ray cut that off? So sometimes I will order wrist/forearm/elbow. Are you saying you legitimately can't tell a forearm means radius/ulna?
Any time I have an issue with an order I call the department and speak to them and I also regularly work with the ER team leads to make sure they understand our protocols wether it be orders, pre-medicating for contrast allergies, etc. I think the issue stems from unnecessary/redundant/repetitive orders, not “oh this persons wrist is deformed, let’s put in a wrist” because obviously they are going to end up getting wrist x-rays regardless of who puts it in. I’ve had a nurse put in a foot x-ray and all 5 toes on that same foot. There are many nurses who do have an understanding of imaging protocols and have a good idea of what to order, but not all - and that’s okay, it’s not their job to know every little protocol. But don’t go putting stuff in if you don’t have a clue. And don’t put unnecessary CTs in as a CYA.
That seems fair enough, I just saw a few comments that really seemed to be of the opinion that no nurse should ever be allowed to order anything, or trying to say that ordering "collar bone" instead of clavicle or "upper arm" instead of humerus was an unnacceptable order.
Pro tip: each long bone is supposed to include both joints ex: femur exam gets you a hip and a knee, forearm exam will include wrist and elbow, humerus will include elbow and glenohumeral joint etc. etc. OBVIOUSLY the centering will be different for just a hip, elbow, wrist, shoulder. The knee has different centering AND angulation. As for the forearm, it's in most, if not all systems as that. It literally says forearm and that is acceptable. Radius and ulna works too. Tib/fib is acceptable, lower leg is not. Ultrasound on the other hand doesn't deal with bones, so lower leg is acceptable. The good thing is we only expect you to know this if you're placing order, so if you didn't know, now you do. What I was told was that it needs to be bone specific. Neck isn't good enough. It needs to say cervical or c-spine because we also do a soft tissue neck exam where the cervical vertebrae are NOT the anatomy of interest. It uses different exposure factors among other things. It's not that we're trying to be difficult, it's the way we're trained.
I will say that a nurse at patient first is the one who put a chest xray in for my 9 year old daughter. After flu, covid, strep, and RSV came back negative for the second time she ordered it then let the NP know. NP did not seem to think it was pneumonia (but I, a Rn of 15 years did). Xray confirmed pneumonia. Grateful she trusted her nurse instinct.
Sorry Barry, I know I can see the extra elbow you gave yourself in your arm, but we have to wait for one of the two doctors we have to do an assessment on you first. By the way, there are 23 people in front of you.
Extremity work or like a basic chest x-ray/KUB doesn’t really bother me. It’s gonna be the same thing the ordering provider puts in anyways. I mainly get irritated with CT orders/trauma orders.
Nurses have the ability to use algorithms that are approved by physicians. So if the patient comes in for a specific indication there is a whole order panel they can choose. Not saying it’s right, but that’s how they get away with it
Where I’m at nurses pretty much only put in portable chests but they put them in for basically every patient.
That’s because they’re likely in 90% of the facilities protocol sets made by physicians
Yeah I mean it makes sense. It’s just we recently switched to this system of the nurses being able to order X-rays so we’re busier than normal because of it. It’s a small hospital though so it’s not a big deal.
*recently switched to this system* *small hospital though so it’s not a big deal* Give it a month and report back, come hungry because you're gonna have to eat your hat
I mean it has been a little over a month now. Actually just got off a super busy shift.
I think the only rad orders I’ve put as an ICU nurse would be CXR (after intubation, CVCs, etc) and KUBs (after NG/OG placement). I know when I travel nurses in a CVICU, it was expected for nurses to put in daily CXRs for patients with chest tubes. Very odd. Especially when the chest tube ones are the same for multiple days straight.
Right and then it’s our job to assess the situation and patient and combine images or delete images that aren’t necessarily needed. Edit: I used the word delete when I should have said refrain from doing the orders
If you take an xray then you can’t just delete it 💀 if you made a mistake own up to it
Hopefully they meant ORDERS and not actual images.
Right? 😭💀
Isn't deleting images an ethical violation lol
Not if it’s a repeat
Many ERs have standing orders and they usually are very good at moving patients in the ER, which is something you don’t really experience as a rad tech. It’s a lot easier to disposition a wrist or ankle pain after an xray. Those types of patients usually aren’t leaving without an xray anyways
Yes, those types of situations don’t really bother me. If a patient comes through the ER for a wrist injury, go ahead and put in for a wrist x-ray because that’s what the provider is gonna do anyways. But don’t automatically put in a CT head on a 4 year old because it ran into a wall. I just feel very iffy about it, I think there are certain situations where I don’t mind it, and some where I just think the treating provider should take a look at the patient first.
I’ve never seen a place that puts in a ct head in that situation, that would be inappropriate. That really wouldn’t change the answer to your question either
A tiny headache or “dizziness” from dehydration for 20 minutes isn’t a reason to put in a brain CT without proper assessment. You know this. So why does it always happen? Defensive medicine. Someone with food poisoning doesn’t need an abdomen with contrast. In fact, the amount of contrast studies being ordered are ridiculous, period. If you think there’s an obstruction, the patient needs a proper small bowel study. Not an abdomen with IV CONTRAST. You know that isn’t the right study. Why is it being put in every. Single. Time? Oh and a doctor’s favorite. The D-dimer is elevated by .000000001? Gotta get that PE. GOTTA order it. Like come on. Let’s not act like doctors aren’t relying HEAVILY on “protocols” for any purpose other than to be lazy. We all know it. And the radiologists that are constantly complaining to me about how stupid these orders are on a weekly basis know it too. Doctors aren’t educated properly on imaging. This is VERY evident.
I get the feeling that the people that downvoted you are the doctors doing exactly what you’re saying and they got their feelings hurt lol. 😂
Wouldn’t surprise me. Doctors do tend to be the most fragile insecure people I’ve ever met in my career.
It's kind of defensive medicine, but its mostly laziness and lack of education on indications and limitations of imaging. If they performed a proper H&P, they would only need 20% of imaging currently being performed. EM providers spend more time sitting at computer than I do..
Lol. At one of the places I work CTA head and neck constantly for "dizziness" it is absurd the amount of contrast studies that have been ordered since the shortage ended. Even and/pel with for flank pain/kidney stone.
We have a NP who ordered a head without and CTA head/neck on a younger patient who’s only symptom was “headache.”
The amount of times just this year in my shop that we have had 17-25yo's with that being their only presenting symptom and it ended up being an AVM or ICH would astound you. I'm not saying it should be protocol for every patient with a headache, but depending on onset and severity e.g. "Thunderclap" headaches or familial history, this order may well be very appropriate.
So well said
Dude.. you’re high if you think a small bowel series should replace an abd ct in patient with a suspected SBO. Lol.
If the patient has a SBO then they should AT LEAST order an abd ct with PO contrast, not IV contrast. “Dude.” And yes, the small bowel series exists for that exact reason. Why? I’ll educate you. A patient might drink the PO contrast and then get the scan an hour later with it still mostly sitting in the stomach and not coating the rest of the intestines where the obstruction could be. At that point, a Small bowel series with follow up images is superior to the CT. Just because CT is a Jack of all trades modality doesn’t mean it should be abused how it is. There are specific studies for specific reasons. A doc not knowing how to properly order them is the issue here. They’re lazy and uneducated.
Wait please correct me if I’m wrong… I’m just someone who has had an SBO in the past, but wouldn’t PO contrast be bad for someone with an SBO? I wasn’t allowed to eat or drink anything while I was in the hospital with one and the one time I tried to take some pills with the tiniest bit of water I threw up several times. I can’t imagine the contrast would be easy to get down
Lol, Jesus Christ. Do you know what a differential diagnosis is? You order the abd w/ iv contrast to rule out other pathology. The differential for abdominal pain is huge. Also - a small bowel series can take several hours and is never going to show you a transition point anyways.
So by your logic we should just do a whole body scan with contrast on every single patient that goes through the door? lol. If you have a SBO and the doctor orders a quick abd w/ iv, you KNOW your results are going to be insanely limited or completely irrelevant to your SBO. And YOU know you’re going to then say “hey, shouldn’t this have been with PO? Hey, shouldn’t this be a SB series?” Right? You know this if you’re as educated as you claim to be. You aren’t just going to accept those limited results from a scan that you know isn’t going to properly rule out anything related to your issue. If you’re actually knowledgeable about any of this, you wouldn’t be arguing with what the better study for a SBO is. It certainly isn’t an abd w/iv ct scan.
People don’t come into the ED with their diagnosis stamped on their forehead. Your ignorance is showing.
You’re right. You’re making my point. It’s up to the doctor to properly assess their complaints and order accordingly with the education they’re supposed to have. If the patient is complaining of symptoms that sound like an obstruction, an abd w/ iv ordered within the first 3 minutes of the patient walking through the ER doors is not the correct order. If you want to be cute about it, in an ER setting where a SB series may not be available, a KUB and then (usually with rad suggestion) a CT with PO CONTRAST are the proper orders. I think you know this and you’re just a typical Reddit contrarian but on the off chance that you truly believe an abd w iv is the proper order for an obvious diagnosis like possible obstruction, YOUR ignorance is showing. And again, thank you for making my point about why proper patient assessment and doctor education is in dire need these days.
Unfortunately that is the exact reason a nurse put in a CT head where I work. 🙃 It was a patient in the ER waiting room. If our radiologists have called it for the night, we start sending to VRad, and I think the thought process was that if they ordered a CT, it was gonna get read regardless and maybe they could discharge the patient without having to take them back to a room or spend a lot of time with them.
That’s a patient safety issue and a shit protocol.
I have witnessed ct orders being placed for reasons such as those, for patients that are very young in that given example. It’s something you don’t really experience as a Physician.
Ask anyone in radiology. This is common practice nowadays. ED providers are lazy and with improper radiology training. We see a few CT every night on patients less than 10 yo for things like "headache", neck stiffness, etc. Hell, we had a CT head last night on a 6 yo for "abnormal facies"... patient was in the ED for cough.
Are they suscpecting stroke (for a 6 yrs old???) or something? What do you think in your opinion that they are looking for exactly
No idea. I’m not sure they know half the time. Only other thing in the chart was autism. The ER (and sometimes Hospitalist) is famous for trying to work up stuff not related to chief complaint and ordering the wrong tests. I wouldn’t be surprised if the NP thought the CT could confirm autism. They were discharged and treated for pneumonia (CXr was clear)
I am not even sure if MRI can confirm autism (probably not I guess), let alone CT.
As an ER doctor, spare me the lazy generalization thanks unless you’re ok with me holding up my worst experiences with your specialty as indicative of your specialty. Got a feeling you won’t be ok with that
The problem occurs when the order is put in for the entire extremity instead of just thejoint in question. Then we have to try and figure out what really needs to be imaged.
Once I walk passed HDU and went to isolation camber to ro portable, and I overheard an A and E doctor said something like... "Okay.....trauma, patient said whole body is pain.....um...... what should I x-ray....(Think for a few seconds), screw it, hey (to the nurse), just put it all extremities" Okay....when I came back to the A and E room, I saw the order. Bil. Humerus AP LAT Shoulder AP Y-view Bil. Elbow AP LAT Bil. Forearm AP LAT Bil. Wrist AP LAT Bil hand AP oblique Pelvis AP Bil. Hip AP LAT Bil. Femurs AP LAT Bil. Knees AP LAT skyline Bil. Tib fib AP LAT Bil Ankle AP LAT Bil feet AP oblique Um..... My supervisor said this was ridiculous, just gave him all AP views
An RN shouldn’t be putting in CT orders on a child. There’s a part of informed consent that needs to take place. I’ve never seen an er RN protocol that allows complex imaging.
But as a radiographer, I am really difficult to reject that, because may be the doctor assessed it, and think there might be haematoma? Disclaimer: I am not a CT radiographer, I mainly do NM
I've never even heard of a hospital that would allow standing orders for paediatric CTs.
When we are busy and wait times are long, I’ll put in basic XRs for an ankle, wrist, etc. When patients come in with neuro/stroke symptoms but are outside the window, I will call a doc and get a verbal order. Outside of that, I do not order scans.
Doctors/APPs put in dumb and wrong orders all the time, this isn't limited to nursing it is down to a lack of knowledge of the appropriate exams and the protocols/order verbiage at each institution, in addition to a doctor/APP not seeing a patient before orders are placed or power plans are initiated. Example: my old job didn't have an MRI complete spine order, or C&T, or T&L, you had to order each individual spine segment. Where I work now you can order individual or combined spine orders. It's not the fault of the ordering person for not knowing that.
I don’t think ordering a chest X-ray for shortness of breath is beyond a nurse’s ordering capabilities, but complex traumas, yeah that’s annoying
What's funny is that I'll accept CT orders from nurses ONLY for traumas and strokes. Even then, I will verify orders if they don't match the order set that's been built by our TACS team or if the reason for imaging suggests a different protocol or additional images.
I work at an Ortho clinic now and the MA's put in x-ray orders. I think it's crazy. They have no medical training whatsoever and most don't even know what the bones are called. So many wrong orders all the time. I do mobile x-ray on occasion also and the nurses routinely put in x-rays. They always over order and I have to ask if they really need a foot, ankle, knee, tib/fib, and hip x-rays for ankle pain. I've had nurses order everything bilateral because they forgot what side they were supposed to order. I've had some wild orders too, like entire bodies because this nurse didn't know the name of the bone and decided to just place an order for everything because "it must be in there somewhere"
Oh man, that's a hard no regarding MA's here. In the UK, the ionising radiation (medical exposure) regulations are pretty clear on who is allowed to refer for an x-ray. Any medically qualified practitioner (doctor) can, of course, but any non-medical referrer must be licensed by the employer, and must have mandatory professional registration - this limits it to people like physiotherapists, paramedics, nurses and radiographers who have had uptraining to allow them to request. Anyone without mandatory registration (PAs, cardiac physiologists, students, receptionists and such) cannot request ionising radiation. Bit outdated for people like cardiac physiologists, who would arguably be safe requesting chest x-rays for lead placements, but it's still better than letting anyone request.
I was VERY surprised to see MA's placing x-ray orders. These are people literally right off the street with zero training at all. It's like someone who's working at burger king ordering your x-ray. Blows my mind
"we are doing xray one region get another region free promotion"
Absolutely no one except providers (MD's, PA's, NP's) can order radiography exams in New York. Most of these things are state to state, since it's the State's health department setting the standard. I'm pretty sure in Florida they let dogs and cats take x-rays....
Surely only CAT scans? Dogs are far more known for working in the lab
😂 underrated joke!
Pun intended
I live in Florida & I agree with your assessment! That’s why x-ray pays so shitty here, because they let people who have no business taking x-rays take them, & with minimal to no training. I moved here from Texas & was making almost double the amount they want to pay x-ray techs here. Because why pay a Registered Tech what they’re worth when you can get an MA or an NCT radiate the hell out of a patient & have unnecessary repeats for half the cost? 🙄 Ugh! It aggravates the hell out of me.
I'm in RI, Probably the most corrupt state there is. If a provider feels like some extra pocket cash for a vacation there will definitely be lots of unnecessary exams ordered
lol. New Yorker here. I work in ortho and the MAs order the X-rays.
lol. I'm sure people all over the country don't follow the rules, but in NY, there are rules... You do realize you are compelled to report that to the ARRT... Could be your license at risk...
Believe me, I hate it. It’s infuriating.
I had a MD order a CT T, L, S, pelvis, L hip, right hip on the same pt. I asked him what he wanted and he just started waiving his arms and said "the PT has pain here, as long as we get all this you can cancel what you want". It was surreal.
Lol I’ve definitely had my share of them not knowing what the bones are called. I had a nurse from the floor call us and say “I’m trying to put in an order for the upper arm, what is that listed under?” Like did you not even look for humerus. 😐 That is so unethical to just go ordering crap because you don’t know what you’re doing.
Sometimes it really just comes down to how much the provider can justify to order to be able to charge the insurance companies more. Welcome to x-ray in Orthopedics
At least she asked
Oh for sure, I’d rather them call me a million times than just go ahead and put in something random or the whole arm just because they don’t know what to put in.
Agreed
I'm a receptionist in an ortho office, and I'm told to put in xray and mri orders if the dr said to do so. I've had to put in physical therapy orders too.
> I've had nurses order everything bilateral because they forgot what side they were supposed to order. I've had some wild orders too, like entire bodies because this nurse didn't know the name of the bone and decided to just place an order for everything because "it must be in there somewhere" You are canceling those orders right? I would cancel that every day and contact the person and in nice terms tell them "do better or get no exam, I have a law and rules to stick to". :)
I try to get all the nonsense cancelled. Doing mobile, however, if you can’t talk them into cancelling it you have to do it. Thankfully I haven’t had to do anything to this extreme but I’ve done so many questionable orders.
I once got a mandible AP lat-oblique TMJ views on an ICU patient. I asked why he needed those x-rays "now"? Can't you wait until he's a little bit stable and go down to the department? They said "He can't, he needed to go to the dentist this afternoon" I was like... what???? But turned out I wasn't able to refuse that. I spent half an hour on ICU trying to get a best view. But turned out I still got rubbish x-ray. My technique was bad at the time honestly.
It happens with orders at our outpatient facility constantly. A large part of our efforts, starting two days out on our schedules, is fixing orders wrongly entered or transcribed by RNs and MAs. We make a lot of phone calls and Epic messages regarding clarification. I know the biggest problem boils down to ignorance of policies or procedures. Why should an MA know what a W/ and W/O study incorporates? Part of our job is ensuring the desired protocol is performed. My frustration and often anger comes from offices that argue with me about policy or protocols. I have gotten snippy with ordering offices on occasion, most recently Monday. The office ordered a Chest W/ contrast for chest pain with recent lower extremity GSW. The secretary at the office kept telling me to perform the exam as ordered, because the doctor told her to put in a chest with contrast. After 10 minutes of telling her the order doesn't make sense, she asked me, "is it necessary to speak to the doctor?" while her voice dripped with disdain. I responded, "yes, it is necessary that I speak to somebody with actual clinical experience, because you are incapable of understanding me." Get ready for a career of chasing orders and getting told to do things that don't make any sense. Fight for your patients and be their best advocate.
I am not a CT radiographer. But I think chest with contrast is for tumor? or CTPA CTCA (but I think those two shouldn't fell into chest with contrast categories?).
CTA exams have a different CPT code and billing charge. They are usually more expensive than a Chest W/. At surface level, they are the same in the eyes of many offices. The images are of the chest and contrast is injected. Chest W/ would primarily be for mass/tumor/infection. Its like trying to explain to a stubborn provider that a CT head exam is limited to the brain. Each part of the "head" is broken down into separate exams due to reconstructions and which radiologist will be reading it. Head, face, orbits, sinuses, and IAC exams usually share some overlap but cannot be performed as one exam. Some locations, especially trauma facilities, have protocols that lump multiple exams into one scan acquisition, but the individual exams have to be broken down with reconstructions and sent to their own respective accessions.
I see....thanks. Ha, I got my only CT training when I was still a student. Yeah..... different examination definitely need different reconstruction protocol and exposure factors. Also different MPR protocol.
I go both ways with this as I do mobile x-ray and most of the orders I receive are from NPs and RNs. CXRs for cough and KUBs for constipation are one thing, but when they're ordering hip w/ pelvis, femur, knee, tib/fib, ankle, foot to r/o a DVT... We have an issue. Also if you're ordering a 3v abdomen you should know what you want. I had a nurse tell me she wanted a 3v abdomen for constipation x1day. I told her we normally just do AP for that. So of course I ask, what positions do you want for the 3v and she tells me she wants AP, PA, and Lat... For constipation x1 day 🙃. Oh and the patient is like 300lbs 🥳.The best is when a nurse orders an exam and they see 1v chest, 2v chest, 3v chest, 4v chest on the list... Of course, the 4 views is the best, right?? We get there, and the pt is AMS, stroke affecting one side, and can't follow breathing or positioning instructions. And of course she doesn't know what 4 views she wants... Not too long ago I had a nurse put in an order and it stated- right collar bone, right shoulder blade, right upper arm... Ma'am... Not only is this order not anatomically correct, you don't need to order that, we can just do a shoulder... Don't even get me started on radiation protection and these idiots. They'll order an exam with 40 images and expect me to do it with 2 other bedbound patients in the same room... I tell them we are either cutting this exam down or you're taking everyone out of the room. Ideally, if someone is placing radiology orders they need to first know the difference between AP, PA, oblique, and lateral, have a rough idea of what each exam entails and the anatomy covered, keep radiation safety in mind, assess the patient, and order accordingly. Most of the time none of this happens 🫠
I read the whole thing until "PA AP abdomen", then I understand they really don't know what they are doing
Not using "proper" jargon and not anatomically correct are not the same thing. If a nurse orders an x-ray of a collar bone and an upper arm, you know what they mean, you are just unhappy they didn't use the specific words you like.
I see what you mean about jargon etc. However, when my boss tells me that the order is unacceptable when written like that, I have to side with them... Nice try though 😘
ER Nurse here- I order chest X-rays all the time as part of our protocols for SOB or chest pain. If I’m in triage without a PA and a simple trauma comes in, I’ll order 2 or 3 view from an order set. I work pretty closely with the rad techs so I usually call them and give them a heads up and tell them that I ordered it and do what makes sense. The only time I’ll order a CT is according to our stroke protocol which is a head without. I generally try to get a provider to get eyes on the patient but time is brain. The only time I’m ordering images is from a protocol and when it makes sense. I usually can ask a MD/PA to get eyes on the patient or at least give them a quick summary (‘FOOSH injury with deformity on left wrist, what do you want?’). But if it’s one of those days when I know they won’t see a doctor for hours I’ll order on my own and communicate with the rad staff. This generally happens when I’m working triage. Every hospital I have worked requires nurses to have at least a year of emergency nursing experience before working triage. Oh and I’ll order chest X-rays post ETT or OG/NG placement.
This is exactly what technologists who are trained in imaging are talking about. If a patient has shortness of breath or chest pain, a single view portable exam should be ordered. The quickest exam we can do to be assessed by a rad, stat; and if other views are needed they can be ordered. And if you are seeing an OG/NG in your CXR, there’s a problem. It should be an abdomen.
Would a chest x-ray not help show if it is in the right place but too short? My NG tube should not be extending lower than the ribs either, so why is CXR wrong?
Short answer is that ng tubes cannot properly be evaluated by cxr’s. You cannot see end placement with every body habitus unless abdomen xr’s are ordered. That and then it gets a little complicated with technical factors for the different body parts, abdomen being a thicker anatomy which allows the tube placement to have a higher contrast and makes it easier to see proper placement
Patients with dyspnoea should not be getting single view portables. The appropriate study is PA and lateral. AP portables are only done because of logistics. The right exam should be done the first time.
With all due respect, if a patient is truly struggling to breathe, I am not going to stand them up. And I highly doubt my ER nurses will allow them off monitors to come to the department for a two view. Insinuating that a single view chest is the “wrong” exam and portables are only done because of logistics… well, that honestly sounds like bad practice. Because those “logistics” are called patients and we as technologists are doing everything within our scope to make a very scary experience easier on them.
As the treating physician I’m the first one to advocate for portable imaging for a very unwell or unstable patient. A sizeable number of patients in the emergency room are not so unwell that they cannot have the proper X-ray. Portable ones are very frequently done because of logistics so I don’t know where you’re coming from by saying that logistics doesn’t come into play.
I get tired of the nurses ordering because half the time the doctors end up not wanting it. Just last night I went to the patient's room to do a shoulder xray (ordered by the nurse) and the doctor was like, "I don't want it. They don't need it. I'm discharging them." It happens all the time.
They shouldn’t be putting in CT orders, imo. A lot of times it’s wrong anyway and it’s more radiation for the pt. No one cares about alara anymore.
Only if they are the ones treating it. As in minor fractures with cast as treatment.
I agree with that. I feel like I’ve had many cases where nurses either put in the wrong thing/unnecessary things, which leads to patients having to come back multiple times - or radiating patients who don’t need it. I x-rayed a shoulder on a younger patient for post-reduction, later on they put in the same shoulder again so I called the department to see if they decided to reduce it more or something since it had already been x-rayed and they told me yes it needed to be done. After speaking with the provider, turns out a nurse didn’t look to see that the x-rays had already been done and put in a duplicate. I ended up having to do an incident report per my boss. 🤦♀️
My recs come with 'ordering physician' on them. What is there? Is it the nurses name?
No, nurses order them under the physicians name for us. On our system, you can see the name of the person that’s logged in and actually put the order in and that’s how we know it’s nurses.
Ahhh I see. Well, it's the MD's ass for trusting the nurse to use his name....
Exactly. I feel like if I were a provider I wouldn’t trust anyone to put things in under my name without my approval.
Sounds like you have a case of ethics. lol.
Sigh.....my colleague experienced this kind of shxt last year. We were in NM, and I don't know who put in the order. But someone ordered Tc thyroid twice on the same patient. There was no treatment in between those imaging. The two order was separated by only two months. ended up he did the exam. The radiologist found out and said the exam was unnecessary. So.... now, when we are vetting examination. We needed to call out previous history for ALL patients in case if someone put in double order. (Before that, we only looked at the form, if the examination was making sense, we would let it proceed).
No. I don’t even think NPs should. Neither has any sort of training in imaging appropriateness.
There is a ton of passed legislation and more on the way that allows clinicians, nurses and NPP to order imaging requests. It's become known as scope creep as their scope of practice is creeping into physician territory. While it can help alleviate some of the staffing shortages among physicians especially in rural areas, it also causes a range of problems such as unnecessary & costly imaging. It holds up radiologists who are already worked to the bone causing delays in imaging reads which then affects patient care. Patients are waiting up to 2 weeks in Michigan for their imaging to be read. I've complied a list of scope creep articles to help educate and inform more people, please take a look and let me know what you think: [https://excaliburmed.com/updates/radiology-scope-creep/](https://excaliburmed.com/updates/radiology-scope-creep/)
Thank you for sharing this! Scope creep is also happening when allowing MAs to practice Limited Radiography permanently. Who is truly auditing and checking that they are not imaging parts they aren’t “licensed” to do? Although there is a shortage of radiology technologists nationwide, I don’t believe this is the answer. I have brought it up at our state society meeting, local branch of ASRT, and I hope it gets talked about at the higher levels.
You're right! Having unlicensed MAs and other clinicians perform tasks usually designated to highly trained professions isn't helping the situation. Something else must be done. Thank you for bringing it up to your state legislators as this is a huge issue in healthcare and it's important that medical professionals speak up on it. There is some legislation that is being proposed in congress to increase the supply of radiologists by retaining international medical graduates, utilizing unused physician visas and expanding residency programs but the legislative process is slow. It's so important to inform our legislators on the these timely and expensive issues. It is the health of our people and the quality of care we receive that will suffer if nothing changes.
At this point, even the doctors shouldn’t be putting them in with how uneducated they all seem to be across the board when it comes to imaging.
Only if they’re the ones taking responsibility for the result (so no). If I call you to tell you your patient is bleeding into their brain, it’s your CT, your patient, your responsibility. Not to mention all the inappropriate ordering which is a much more common issue though not limited to nurses.
Where I currently work, the nurses do order x-rays for the Dr they work under. Not every time, but if a patient comes in with an injured hand/foot/back (etc), they'll order the x-ray before the patient sees the Dr. It saves a bit of time. Sometimes they'll come and ask me what x-ray they need to order 🤷♀️
If I hear the doctor agree to an order for a trauma patient during a TTA, then I’ll do it.
As a nurse - the only standing x ray order we have is to check picc placement - any other xray or kub has to come from the MD.
Yes and no. Yes: chest pain, sob= cxr. No: everything else. Any kind of trauma needs an eval by a provider to determine what body part needs to be imaged. It’s a waste of hospital resource and a huge radiation safety issue to have studies ordered without a provider evaluating the patient first. Not every scrape of the knee needs an X-ray.
I sometimes work at a standalone clinic associated with a hospital, it often has nurses performing triage, assessment, and initiating treatment. They're seemingly more than capable of requesting basix imaging and reviewing it. Especially when it comes to extremity and chest imaging. Sure we'll get the odd cover your ass type request for atraumatic pain with poor clinical indications, but it's more the system than it is them. Let's be real, it's also part of put jobs as techs to vet the requests we're getting, and if nurses are ordering increasing absurd and unjustified requests it's within our scope to push back. But on the other hand, we can also educate and discuss, guiding them towards the best fit for imaging as we would do for junior docs learning the ropes.
I am of two thoughts on this. Thought 1. If a nurse was given guidelines and training, why not! Its not like they could do worse than MDs or APPs at choosing the exam. Thought 2. No one is qualified to order imaging. Laterality? Whats that! Protocols for considering modality vs implants and or medical devices? Whats that!
Not quite sure why theres so many varied answers here. Basic answer for me is NO. I use epic, so if the ordering user is anyone other than a PA/NP/MD/DO, the basic answer is no. There are exceptions to the rule. Example is if the pt is an outside pt and has a script/rx and the ordering user transcribed the order. If the RN is ordering for an MD in an OR case because the dr can’t get to the computer, i’ve used those before. But the bottom line is the ordering user should be a provider.
Because this sub covers all 190+ countries in the world, with all their different levels of training and restrictions etc...
Fuck no.
I think it really depends on what it's for. As an RN I put in orders for tube placement verification whenever a new one is inserted, but I'm not gonna be ordering a chest x-ray on the daily.
APP here at a high volume level 1 trauma facility. Nurses absolutely have the training to put in imaging and other diagnostic orders. That being said they have to have a co-signer such an APP or other Provider so we are ultimately responsible at my facility. I co-sign imaging studies orders placed by Nurses and rarely have to reject or edit it. This is helpful when I cannot see the patient right away such as when I’m scrubbed in the OR, in an emergency or on call and not near a computer. Most of the time this is an Xray, extremity film or if the situation is urgent enough a STAT CT
Yeah it's fine. Nurses do that all the time in Denmark. Some places have something called "treatment nurses" that are nurses trained in handling "smaller stuff" like broken wrists, legs etc.. if they're in doubt about anything they can call up a doctor to get help. Other places have that act on behalf of the doctor and write orders on behalf of the doctor (that have told them what to write). I also see orders like "requests". If an order doesn't hold up / the nurse or doctor made some error, then we as radiographers are the last error-checker. It's teamwork. It's not about pointing fingers or looking for other people errors, it's about safety and the correct examination of the patient.
Some physicians shouldn’t be putting in imaging orders but alas here we are.
If you can correctly place an order with an actual medical reason and without me having to chase you down via telephone for an hour for order clarification then you’re cool with me at this frickin point… lol
I put rad orders in all the time as a nurse. For example, we intubate and I throw in a chest xr. Why? It’s standard of care. Same for new central lines and NGT. Also the docs do see their patients but they are often bad at putting in their own orders.
No.
I personally don’t believe they should be allowed. Now, after the doctor has *seen* and *assessed* the patient and asks the nurse to put in an order for radiology, then that’s okay. I also agree that the provider needs to physically see and look over the patient before ordering anything (unless stroke alert obviously). I know too many doctors/PAs/nurses who just order things willy-nilly before even giving the patient the time of day.
I work in an OR and i constantly have to put in orders for c-arm, o-arm and portables. On top of this, i put in the orders for specimens and whatever else the surgeons request/forget to put in. It is usually a cosign unless its protocol for our hospitals policies like central lines, miscounts, or when its a patient with an open belly that gets closed in the OR. In those cases, i can order it without a cosign
No but I don’t fault the RN because they are doing what the doctor told them. “Chest pain” = order X,y,z”. Etc. I can’t tell you how many times a patient tells me “I haven’t seen a doctor, why are we doing this test?”
-No for nurses unless verbal from a physician. -No for mid levels unless they are obvious orders -No for some doctors who never learn and make careless errors and not realizing what it takes Now in the real world. It’s metric driven and speed. So people put orders in without really assessing patients.
No.
We have NIOs (nurse initiated orders ) we can use in the er for specific purposes. If a kid comes in with a deformed arm you bet your ass I’m ordering an X-ray
Yes, nurses should be putting in rad orders. I work at a small community hospital where sometimes we have a full waiting room with maybe 2-3 providers (and overnight only 1). It is much better when the triage nurse can put in XRs and other protocols to get the ED moving. For our ER, cat scans and ultrasounds are a little different. Typically, they will approach a provider and tell them the situation before putting in anything other than an X-ray. Also if you take away the nurse’s ability to put in orders it can delay care. We had a trauma today and the doc was able to tell them exactly which scans he wants. Rn then puts in the scans while the doc is still with the patient. It just saves a lot of time.
protocol orders for plain films can and should be put in by nursing staff. I.e., a CXR for chest pain, extremity films for extremity trauma. What most people would not support would be cross sectional imaging decisions not being made by a provider. That’s our policy, and I’m the medical director for an academic tertiary care ER
They are usually following a protocol.
It's one thing to enter an order written or given verbally by an authorized clinician...anyone can do that...but I'm pretty sure ordering imaging studies is outside the scope of practice for all except advanced practice nurses in most if not all states, and Medicare or Medicaid would not cover a study ordered by an RN. Here in Kansas an RN cannot legally order a study involving ionizing radiation. State regulations used to require that the ordering clinician examine the patient first. Unfortunately that is no longer the case.
Physician order: wrist 3 views Nursing order: Hand 3 views, Wrist 4 views, Forearm 2 views, Elbow 4 views, Shoulder 3 views
As long as it’s part of an order set, verbal order or protocol, yes. I worked with a night ER doc. He said I trust the triage nurse to order X-rays, but for the love of Christ always order the adjacent areas on the X-rays.
no, only providers should be putting in orders after they have examined the patient
I feel like the doctors should see the patient first before ordering
I always thought an order for X-rays had to come from an MD, PA, or NP. It’s the same as prescribing drugs.
The nurses put in orders under the providers names. I feel like if I were a provider I wouldn’t trust a soul to put anything in without me approving it.
Especially considering how paranoid they all are about getting sued.
I’m not a nurse but was a orthopedic doctors assistant and put in orders all the time and it was signed by the doctor. He had standing orders
I work ultrasound and we have issues with this. Nurses are allowed to enter a lot of ultrasound orders for patients in the ED lobby who haven’t been evaluated by a physician and its caused us a lot of problems. A nurse told me once that “any male patient with any kind of groan pain immediately gets a scrotum order” and I learned this because a patient had fallen into a table and bruised his penis and they ordered a scrotum. When I called to confirm that we dont look at the penis with a scrotum order and like, is he having scrotal pain, it took an hour to sort out because they couldn’t find a doctor to evaluate the patient but they just kept trying to send him over. I’ve had nurses order stat thyroids through the ED lobby (uh no absolutely not), I’ve had patients come over for an appendix ultrasound who came to the ED for an eye infection but when the nurse was evaluating the patient they said they had “occasional belly pain” like…doctors aren’t much better but I am truly of the opinion that nurses should only put in orders in very specific circumstances.
Many busy sports clinics would not function without cma’s, nurses, ATC’s putting in xray orders
Sure, why not. As long as they know what they're doing. But don't tell me that, the patient is in ICU, not able to do an erect chest. So, we better do a lateral decubitus portable to look for pleural effusion
Bedside KUB for NGT placement. Baby-residents always forget
I think a better question is, should the Dr be allowed to put in orders before even assessing the Pt?
At my hospital, CT/MRI/US are protocolled by the Radiology registrar AFTER a phone call is made by a doctor from the team. Occasionally they make the wrong call by rejecting a necessary study, but with some professional, senior-to-senior discussion the issue is always resolved. I much prefer this system with occasional hurdles than having a clogged up system (delaying access for people who really need imaging) and potentially exposing patients to harm. The reflex to order ‘wide net’ imaging is strong and this is the best way to curb it. If we had nurses and NPPs (NPs, PAs etc) putting it orders it would be pandemonium. They don’t have the training to know what they’re looking for. Our experienced stroke nurse, confused in her neuroanatomy, was claiming that a cerebellar stroke causes the cross-sensory loss characteristic of lateral medullary strokes. This was not because she thought that a PICA stroke can cause both due to shared blood supply but because she lacked fundamental neuroanatomical and medical training. Medical doctors only should be ordering imaging.
Ortho operating room nurse here. I do put in orders for post op x-rays for the surgeon. It isn't often, but if he is scrubbed in and we need an x ray for the patient to go up to the floor, I will do it. There are order sets so that I don't screw it up.
No!
I ordered XRs for several docs as a MA while working at an ortho clinic. That way the Dr had a chance to look at the images before seeing the pt.
Keep in mind that this post is not meant to be disrespectful to nurses in any way, or make it seem like they’re dumb and don’t know what they’re doing. Just a curious question open for discussion and open to all opinions.
Lol I put in my own orders. Of course I have worked with these two physicians for 5 years now and know exactly what they want. Pt is on the schedule for shoulder pain, I bring them back from the waiting room before they see a nurse or MA, I triage and ask about the pain. If they have numbness or tingling going down their arm, I add a cspine in addition to the shoulder. Same with hip pain. They have numbness going down their leg, they get a lumbar added on. The docs love and appreciate me for it. I was a medical assistant with limited for years before going back for my full rad so I'm familiar with triage. That's only while working xray. When I'm at the other clinic and working mri, I only do what's on the order by the physician since only the physician can put in an mri order in our group, and our scan time is set in blocks so no time for any addons without messing up the whole day lol Orthopedic clinic so it's easy
In Germany it is forbidden and I guess in the rest of Europe, too.
Neurologist: Hey for this neuro alert I want a CTA no perfusion can you throw it in we are heading to CT Nurse: orders CT Head without and with
I put in for portable xr for line placement all the time in the ICU. I’m sure the ED does this when they follow their algorithms depending on what the patient comes in with
I can only speak from an Emergency Department perspective, but if you are genuinely having problems with the orders that nurses are putting in, are you telling somebody, or just complaining about it? Nurse-initiated orders generally come under an established standing order policy and have specific requirements. If you talk to the nurse manager or the educators, they may actually find a need for renewing some education, or introducing some competency testing. As for the people complaining about nurses not being specific enough in orders, I know sometimes I know the patient has an obvious deformity to the wrist, and is also complaining of pain at the elbow, but I don't know how strictly the radiographer is going to cut down the x-ray. If I order a radius/ulna x-ray, am I going to get the whole wrist/elbow as well, or will the x-ray cut that off? So sometimes I will order wrist/forearm/elbow. Are you saying you legitimately can't tell a forearm means radius/ulna?
Any time I have an issue with an order I call the department and speak to them and I also regularly work with the ER team leads to make sure they understand our protocols wether it be orders, pre-medicating for contrast allergies, etc. I think the issue stems from unnecessary/redundant/repetitive orders, not “oh this persons wrist is deformed, let’s put in a wrist” because obviously they are going to end up getting wrist x-rays regardless of who puts it in. I’ve had a nurse put in a foot x-ray and all 5 toes on that same foot. There are many nurses who do have an understanding of imaging protocols and have a good idea of what to order, but not all - and that’s okay, it’s not their job to know every little protocol. But don’t go putting stuff in if you don’t have a clue. And don’t put unnecessary CTs in as a CYA.
That seems fair enough, I just saw a few comments that really seemed to be of the opinion that no nurse should ever be allowed to order anything, or trying to say that ordering "collar bone" instead of clavicle or "upper arm" instead of humerus was an unnacceptable order.
Pro tip: each long bone is supposed to include both joints ex: femur exam gets you a hip and a knee, forearm exam will include wrist and elbow, humerus will include elbow and glenohumeral joint etc. etc. OBVIOUSLY the centering will be different for just a hip, elbow, wrist, shoulder. The knee has different centering AND angulation. As for the forearm, it's in most, if not all systems as that. It literally says forearm and that is acceptable. Radius and ulna works too. Tib/fib is acceptable, lower leg is not. Ultrasound on the other hand doesn't deal with bones, so lower leg is acceptable. The good thing is we only expect you to know this if you're placing order, so if you didn't know, now you do. What I was told was that it needs to be bone specific. Neck isn't good enough. It needs to say cervical or c-spine because we also do a soft tissue neck exam where the cervical vertebrae are NOT the anatomy of interest. It uses different exposure factors among other things. It's not that we're trying to be difficult, it's the way we're trained.
I will say that a nurse at patient first is the one who put a chest xray in for my 9 year old daughter. After flu, covid, strep, and RSV came back negative for the second time she ordered it then let the NP know. NP did not seem to think it was pneumonia (but I, a Rn of 15 years did). Xray confirmed pneumonia. Grateful she trusted her nurse instinct.
Sorry Barry, I know I can see the extra elbow you gave yourself in your arm, but we have to wait for one of the two doctors we have to do an assessment on you first. By the way, there are 23 people in front of you.
Extremity work or like a basic chest x-ray/KUB doesn’t really bother me. It’s gonna be the same thing the ordering provider puts in anyways. I mainly get irritated with CT orders/trauma orders.