Radjak Hospital ...................................

FORMULIR PEMERIKSAAN RADIOLOGI KONVENSIONAL/ CONVENTIONAL RADIOLOGY EXAMINATION FORM

Nama Pasien: Umur : Jenis Kelamin : No Rekam Medis :

Alamat : Dokter Pengirim : Ruangan : Tanggal :

Klinis :

Beri tanda (X ) untuk pemeriksaan yang diminta: No. Foto :

□ Cito □Hasil untuk Dokter □Hasil untuk Pasien

Conventional without Contrast

Central Venous System Abdominal Pelvic & Teeth, Orbita, Nose, Ear System
Gastrointestinal
□ Cranium PA + Lateral □ Abdomen AP (BNO) □ Orbita
□ SellaTursica □ Abdomen 2 Posisi □ Foramen Opticum
□ Vert. Cervical AP + Lateral □ Abdomen 3 Posisi □ Nasal Bone
□ Vert. Cervical AP + Lateral + Oblique □ Pelvis AP □ Sinus Paranasal 3 Posisi
□ Vert. Cervical Dynamix Lateral □ Pelvis Lateral □ Sinus Paranasal 2 Posisi
□ Vert. Cervicothoracal AP + Lateral □ Alar / Obturator View □ Water’s / Towne
□ Vert. Thoracal AP + Lateral □ S.I. Joint □ Mastoid
□ Vert. Thoracolumbal AP + Lateral □ OsPetrosum
□ Vert. Lumbal AP + Lateral Extremitas&Articulatio □ Zygomatic Bone
System
□ Vert. Lumbal AP + Lateral + Oblique □ Manus □ Maxilla
□ Vert. Lumbaosacral AP + Lateral □ Wrist Joint □ Mandibula (Eisler)
□ Vert. Lumbalsacral AP + Lateral + □ Antebrachi □ TMJ
Oblique
□ Lumbal Flexi - Extensi - Lateral □ Elbow Joint □ Cephalometric
□ Vert. Sacral / Coccyx □ Humerus □ Panoramic
□ Whole Spine □ Shoulder Joint
(Cervical+Thoracal+Lumbal+Sacral) □ Clavicula Other
□ Scapula □ ……………………………………………………….....
Respiratory System □ Pedis □ …………………………………………………………..
□ Thorax AP / PA □ Ankle Joint □……………………………………………………………
□ Thorax Lateral □ Calcaneus
□ Thorax PA + Lateral □ Cruris
□ Thorax PA + Lordotic □ Genu / Knee Joint
□ Top Lordotic □ Femur
□ Sternum □ Hip Joint
□ Costae
□ Thorax – Abdomen (Babygram)

Conventional with Contrast*

Gastro Intestinal System* Urogenital &Obsgyn System* Nervus System*

□ Sialografi □ BNO IVP □ Myelografi
□ Oesofagografi □ Cystografi
□ Maag Duodenum □ RPG (Retrograde Philography) Other*
□ Oesofagografi Maag Duodenum □ MCU (Micturating Cysto □ CorAnalisa
Urethrografi)
□ Follow Through □ Urethrografi □ Fistulografi
□ Appendicografi □ HSG (Histerosalfingografi) □ Phlebografi
□ Colon In Loop □……………………………………………………………
□ Lopografi

*Persiapan khusus, harus melalui perjanjian dengan Bagian Radiologi/ menghubungi nomor 021 3904422 (ext. 1103/1104)
Special preparations,for reservation please contact Radiology Department/ call the number 021 3904422 (ext. 1103/1104)
NOTE
Waktu Input
Radiografer
Radiologist
Perawat
Pemakaian Film / CD
001-FORM-RAD-IX-2021 FaktorEksposi : ……. kV, ……. mAs, ……s