CT增强检查知情同意书

xx医院CT增强检查知情同意书患者姓名：科别：医保证号：病案号/门诊号：放射科号：在CT扫描中，当病变组织与正常组织密度接近时，形成的CT图像自然对比度低，病变细织不易显示，这样单纯CT平扫容易遗漏病变：而CT增强扫描，是指经静脉注入含碘造影剂后再行扫描的技术，当体内注入造影剂后，不同的组织结构及病变性质，由于含碘造影剂的分布及数量都有不同，这样病变组织和正常组织之间的图像对比度增加，两者之间的界限也比较清晰，帮助发现平扫未显示的的病变、明确病变的范围及边界。

另外CT增强扫描还有利于鉴别病变的良恶性，提高检查的敏感性和特异性。

一、医生告知我CT增强检查期间可发生的一些风险：（一）不同患者具有个体差异，存在以下风险：1.CT增强检查用的非离子型碘造影剂，安全性高，一般不会发生药物反应，但极少数患者由于特异体质或各种不能预知的原因，可能发生过敏及肾功能损害等不良反应，极少数严重者会危及生命。

不同程度的过敏反应具体表现有：(1)轻度反应：荨麻疹、头痛头晕、恶心呕吐等；（2）中度反应：口舌发麻、结膜充血、胸闷气急、发音嘶哑等：(3)重度反应：呼吸困难、血压骤降、意识丧失、休克、呼吸心跳骤停等。

2.CT 增强扫描使用高压注射器做静脉团注(即短时间内快速大量注射)，当患者血管较细小或较脆弱时，可能出现造影剂外漏入血管周围组织间隙内，引起局部水肿、疼痛，极少数严重者可导致局部组织坏死等。

3.除上述情况外，在检查过程中有可能发生其他不能预料的意外情况，特别是对于重症患者、继往有心脑血管疾病的患者。

（三）既往有碘造影剂过敏史，应提前告知医生并禁止使用增强检查。

（四）过敏反应多在注药后20分钟内出现，应在检查结束30分钟后再离开医院，如出现上述造影剂风险应及时告知医生。

若离院后出现不适，应速在就近医院诊治。

（五）如出现CT增强检查不良反应，医生将积极给予相应处置，患者家属应予理解和配合。

（六）CT增强检查过程中如果体位不当或不遵医嘱，可能影响检查效果。

庆阳市第二人民医院CT增强检查知情同意记录单门诊号住院号根据诊疗需要，患者于年月日在CT室行CT增强检查，现将有关情况告知患者及家属：进行CT增强检查，需经静脉（常规为上肢静脉）注射含碘对比剂，以增强病变与正常组织的密度差别，有助于清楚显示病变，提高诊断的准确性，使用过程中，部分患者可能会产生过敏反应，如果您之前有碘过敏、青霉素过敏者应主动说明。

目前用于CT增强检查的对比剂主要为非离子型对比剂，产品有“优维显”、“欧乃派克”、“安射力”、“碘比乐”等，为国家正式批准使用产品。

在使用过程中，极少数患者可能出现不同程度的毒、副反应。

对比剂毒、副反应分为以下几种，其临床表现有：轻度反应：全身热感与发痒、头晕头痛、皮肤红疹、恶心呕吐、喷嚏咳嗽、结膜充血等。

中度反应：全身出现（荨）麻疹、眼睑、面颊和耳部红肿、胸闷气急、呼吸困难、声音嘶哑、肢体抖动等。

重度反应：面色苍白、四肢青紫、肌肉痉挛、呼吸重度困难、大小便失禁、血压骤降、意识丧失、休克、呼吸和心跳骤停等。

鉴于上述情况，特别提醒患者及亲属注意以下几点：1、有重度心、肾功能不全、甲状腺功能亢进者，禁忌CT增强检查。

2、有哮喘、糖尿病、高血压、严重心脏病、过敏体质及高龄患者，建议谨慎做CT增强检查。

3、一般轻度过敏反应多在注射对比剂后即刻或约20分钟左右时出现。

因此，请在检查结束后等待30分钟再离去，以便观察。

如出现上述对比剂毒副反应，或有其他不适表现，请及时通知工作人员。

若您离开医院后出现上述情况，请即刻到就近医院或来我院就诊。

4、CT增强检查时，需要使用高压注射器，向静脉内快速、大量（约100毫升）注射对比剂，对于长期患病治疗者、血管较细和较脆弱者，可能在注射部位出现对比剂漏出血管外，引起肢体组织肿胀、疼痛，极少数严重者可能会导致局部组织坏死等。

5、出现上述对比剂毒副反应后，我们将积极给予相应处置，请患者和亲属予以理解和配合。

6、所有做CT检查的患者，均实行实名制。

南充市第五人民医院
放射科造影检查知情同意书
门诊号 C T号
住院号 X线号
患者姓名性别年龄身份证号码
根据患者的病情和影像诊断需要，需做造影或CT增强扫描检查，在检查之前需要注射含碘造影剂。

该方法是一种常用的帮助提高诊断和治疗的有效手段，但具有侵入性、造影剂过敏等风险。

现告知如下，包括：
1、碘造影剂一般安全可靠，但有极少数患者由于其体质特殊可能会发生难以预料的各种类型的过敏反应（有皮疹、痒感、呼吸困难、心慌等表现），严重者可导致过敏性休克甚至死亡。

医师在注射造影剂之前虽然进行碘造影过敏试验并证实为阴性反应，但仍不能保证该方法的绝对效果和安全。

2、其它无法预料或难以防范的不良后果。

3、患者须向检查医生提供以下情况，如果患者有造影剂禁忌症，将不能做造影检查。

（1）过敏史：
（2）既往史：
（3）现病史:
(患者或代理人签字）
我已阅读上述内容，对医务人员详细告知的可能发生的风险表示完全理解，经慎重考虑，我同意注射碘造影剂，并自行承担由此引起的不良后果。

我明白在本次检查中，在不可预见的情况下，可能需要其他附加操作或变更检查/治疗方案，我授权医师在紧急情况时，为保障患者的生命安全实施必要的救治措施，并保证承担全部费用。

我知道在本次检查开始之前，我可以随时签署拒绝检查的意见，以取消本知情同意书的决定。

患者/法定代理人签字
委托代理人签字
联系电话
日期：年月日时分。

Modern Hospital GuangzhouInformed Consent of Enhanced CT ScanPatient name：Sex：Age：Case No：Bed No: Radiology Dept No:Introduction of enhanced CT scanIn CT scan, as density of diseased tissue is close to that of normal tissue, the CT image will be of low contrast. As a result, the diseased tissue is not shown clearly, and plain CT scan may omit some of the lesions. Enhanced CT scan is the technology that scanning is performed after contrast media injected intravenously. After the injection of contrast media, distribution of contrast media will be different in different tissue structures and lesion natures. In this way, image contrast will be improved between normal tissues and diseased tissues, and borders between the two will be clearer, which will show the lesions that missed by plain CT scan and clarify the extent and border of lesions. Besides, enhanced CT scan is helpful in verification of malignant or benign lesions, and improvement in sensitivity and specificity of examinations. In addition, enhanced CT scan is safe in most cases.OtherPotential risks and handling:I have been informed that this procedure carries potential risks. However, certain uncommon risks are not included hereinto. The method of surgery should be individualized based on medical condition. I have been informed that I am entitled to discuss with my physician regarding the surgery and any associated special questions.1．I understand that all enhanced CT scan carry potential risks.2．I understand that individual differences of patients, and risks are listed in the following: Non-ionic iodinated contrast media in enhanced CT scan is of high security, and drug reaction will not occur in most cases. However, under extreme cases, there may be some adverse reactions such as allergy, renal function damage, and other reactions, and even life-threatening events may occur, which are of extreme difficulty in prediction by modern medical technology. The allergic reactions are as follows：1)Mild reactions: urticaria, headache, nausea, dizziness, vomiting, etc.2)Moderate reactions: numbness of mouth and tongue, conjunctival congestion, chestdistress, short of breath, hoarse voice, etc.3)Severe reactions: difficulty in breathing, sudden decrease of blood pressure, loss ofconsciousness, shock, respiratory arrest and heart arrest, etc.Because intravenous bolus injection technique (large amounts of injection in short time and in rapidity) is adopted in enhanced CT scan. If patients’blood vessels are thin or vulnerable, contrast media may leak outside of the veins to the surrounding tissue interspaces, which will cause local swelling, pain, and local tissue necrosis in extreme cases.Besides the conditions above, there may be some unpredictable incidents, especially in some patients with critical conditions or case history of cardiovascular and cerebrovascular diseases.3．I understand that if I have allergic history of iodinated contrast media, I should tell the doctors in advance and stop the enhanced CT scan.4．I understand that allergic reaction mainly occurs in 20 minutes after the injection, and I should not leave the hospital until 30 minutes after the examination. If the risks caused by contrast media occur, I should tell the doctor in time, and if I feel discomfort after leaving hospital, I should go to the hospital nearby for treatment.5．I understand that if adverse effects occur, appropriate treatment will be given, and my family members should be cooperative and understanding.6．I understand that if I don’t follow the doctors’ orders or in an inappropriate position, the result may be affected.7．I understand that patients with severe heart disease, cardiac insufficiency, diabetes, renal insufficiency, asthma, thyroidism, etc, or with great age, allergic constitution, overstress and anxiety, should tell the doctor in advance to receive prudent evaluation. Besides, we should be accompanied by family members or doctors, especially in the emergency treatment during nights.8．I understand that due to complexity of disease and limitation of imaging examination, there may be possibility that definite diagnosis is not made after enhanced CT scan.Special risks or major high-risk factorsI understand that the following special complications or risks may occur under current medical condition, apart from the forementioned situations:Choices of the patient’s informed consentI have been informed of risks, incidents, and unpredictable situations in usingcontrast media during the enhanced CT scan. All questions regarding thisprocedure have been properly answered.●I agree that adjustments to scheduled method of examination according to mymedical condition. If there is risk or incident, I authorize doctors to do theprocedures based on medical routine.●I understand that this procedure requires the collaborative efforts by severalphysicians.●I understand that I should do the payment of enhanced CT scan afterexamination.●I am not ensured a 100% clear diagnosis of this procedure.●I authorize affected organs, tissues and specimens as well as imaging data thatare involved in this procedure can be handled by the physician, which includepathological and cytological examinations, scientific studies, medical wastedisposal, etc.●For the best of knowledge, I have disclosed my medical condition to thephysician in a truthful and thorough manner. I shall bear all the consequences asa result of hidden truth.Signature of patient Date of signature DD MM YY Hr MinID No. TelMailing addressSignature of authorized family member should be obtained in the event that the patient was unable to sign informed consent:Signature of authorized family member Date of signature DD MM YY Hr MinRelationship with the patientID No. TelMailing addressStatement of physicianI have informed the patient complications and risks of enhanced CT scan, and answered all questions regarding this procedure.Signature of physician Date of signature DD MM YY Hr Min。

(word完整版)放射知情同意书
东莞市大朗医院
放射检查知情同意书
姓名：性别: 年龄：科室：床号：门诊（住院）号: 尊敬的患者及家属：
1、根据你的病史、体格检查及其他辅助检查，你有必要进行放射检查。

2、放射检查（包括X光检查、CT检查、MR检查）是一种对人体健康有一定影响的影像检查技术，但放射检查具有一定的局限性，实施检查将有助于提高发现疾病的机率，但有别于病理检查，影像诊断意见仅供临床参考。

3、病情随时间可发生变化，因而可能造成前后检查结果不一致。

4、X射线照射可能会引起胎儿死产或流产、胎儿畸形、新生儿智力低下、造血系统和神经系统缺陷等不良后果，妊娠期间不宜进行放射检查;育龄妇女请如实告知月经史（末次月经时间: 年月日，由患者填写），存在月经紊乱、月经不调及月经不规律等情况的育龄妇女必须慎重或明确无怀孕后再进行放射检查.
5、因目前医学检查对怀孕早期的诊断有一定的局限性，HCG或B超等辅助检查结果阴性并不能排除已怀孕，近期计划怀孕期间的适龄妇女不宜进行放射检查。

以上内容，受检者及家属已充分了解，并清楚放射检查包括的项目、内容、性质、目的及局限性，对其中的疑问已得到经治医师的解答，医方已履行了如实告知义务,患方已享有充分的知情同意及选择权利，□同意□不同意放射检查。

受检者（或家属)签名: 医生签名：
日期：年月日时分日期：年月日时分。

CT检查使用碘对比剂知情同意书
CT增强检查需经静脉注射碘对比剂，一般安全顺利，偶尔会出现下列情况：
1、少数特异体质者可能会发生不同程度的不良反应：轻度不良反应表现为咳嗽、喷嚏、一过性胸闷、结膜炎、鼻炎、恶心、全身发热、荨麻疹、搔痒、血管神经性水肿等；重度不良反应表现为喉头水肿、反射性心动过速、惊厥、震颤、抽搐、意识丧失、休克等，甚至死亡或其他不可预测的不良反应。

迟发性不良反应表现为注射碘对比剂后1小时至1周内出现晚发性症状，如恶心、呕吐、头痛、骨骼肌疼痛、发热等。

2、使用高压注射器，存在注射针头脱落、局部血管破裂的潜在危险。

注射部位可能出现碘对比剂漏出，造成皮下组织肿胀、疼痛、麻木感，甚至溃烂、坏死等。

3、在CT增强扫描过程中，由于患者心率不齐、心率异常、呼吸异常、位置变动等造成的扫描失败，重新扫描所需的对比剂费用由患者承担。

有鉴于此，既往有碘对比剂不良反应史、甲亢、肾功能不全及哮喘病人慎用或禁用碘对比剂；检查过程中若出现身体不适及时告知医务人员以便采取相应的处理；CT增强扫描结束半小时后离院，以便观察；使用二胛双胍类药物的糖尿病患者停药48小时后做此检查；检查后多饮水有利于碘对比剂及时排除。

目前各种现代化医疗措施对出现药物不良反应尚难事先预防，因此在CT增强检查前需办理“同意给药”、“知情同意”的签字手续，请患者及家属予以协助。

若发生上述情况属医疗意外，同意做此检查请签字
患者姓名：患者亲属或监护人姓名：
签署时间：年月日。