Referral form
Ontario Diagnostic Imaging Requisition
An Ontario diagnostic imaging requisition tells the radiologist what to image, why, and how soon. Hospitals and independent health facilities each print a PDF. OHIP still needs a licensed prescriber, a clinical indication, and enough history to protocol the study. 'Pain, please image' is how the request sits in a pile or comes back as the wrong test.
What the requisition has to do
Name the modality and the body part. CT chest is not 'chest imaging.' Ultrasound abdomen is not 'rule out everything.' If you want CT pulmonary angiogram for suspected PE, write that, with Wells elements or the equivalent you used, not 'SOB.'
Use the facility's current form so booking has the right fax and the right safety questions (eGFR, contrast allergy, pregnancy, metal, e-GFR for MRI contrast). A pad from another hospital will land in the wrong queue.
Choosing Wisely is not a slogan on the form
Low back pain without red flags does not need early MRI because the patient asked. If you are ordering it anyway, write the red flag. If there is none, do not order it to 'close the visit.'
Who may order
Physicians and other professionals authorized to requisition that modality in Ontario. Stay inside scope. An order you cannot act on is still your result to follow. Copy-to the clinician who will actually manage the finding.
How to complete the requisition
- Patient identifiers and OHIP number. A transposed health card is someone else's abdomen.
- Modality, body part, laterality, contrast yes/no if you know.
- Indication: the clinical question in one or two lines. Suspected PE, Wells 4.5, HR 110, SpO2 93% on air, no hemoptysis.
- Urgency: today / within 24 h / routine. Do not mark 'ASAP' on a screening ultrasound.
- Relevant history: cancer, surgery, prior imaging date and where, anticoagulation, pregnancy.
- Safety: eGFR if you have it, allergy, implants for MRI, metformin if relevant to contrast.
- Copy-to and a number that is answered. Critical results to a dead fax are your problem.
Worked example (fictional)
CTPA — suspected PE in clinic
Fictional 57-year-old. Do not copy onto a real requisition.
Facility: local hospital DI, current CT requisition. Study: CT pulmonary angiogram. Contrast: yes. Indication: acute dyspnea 12 h, pleuritic right pain, HR 108, SpO2 93% RA, Wells 4.5 (HR, immobilization after knee arthroscopy 10 days ago). No hemoptysis. ECG sinus tach, no ischemic ST. D-dimer not used (high pretest). Urgency: same day / send to ED if slot not available this afternoon — discussed with patient. eGFR 78 last month. No contrast allergy. Not pregnant. Copy-to: ordering FP, fax on form. Patient told to go to ED if worsening before the scan. Not a 'routine chest CT.' Not a V/Q (no known contrast issue).
Why DI sends the requisition back
- No clinical question.
- Wrong laterality or no body part.
- MRI without implant/metal answers.
- Routine priority on a query PE or query cauda equina.
- Illegible handwriting and a fax that does not exist.
Draft the imaging requisition from the visit
In Scribeberry, open Forms, search for Ontario diagnostic imaging requisition, or upload the facility's current PDF. Generate from the encounter and your notes, then edit every field before you sign. Scribeberry does not pre-map this form. You still review and sign.
Frequently asked questions
Can I order MRI for mechanical back pain at week two?
Not as a default. If there are no red flags, say so and do not order. If there are red flags, name them on the requisition.
Who follows the result?
The ordering clinician, unless a documented copy-to clinician has accepted that role. Put the copy-to on the form.
What if the patient wants a specific facility?
Use that facility's requisition if you are willing to send there. Wait times and protocols differ. The clinical indication does not.
Does Scribeberry book the scan?
No. Scribeberry helps you complete the PDF. You send it to DI and keep a copy in the chart.
Forms
