1. MARY HITCHCOCK MEMORIAL HOSPITAL
EMERGENCY DEPARTMENT
EMERGENCY DEPARTMENT
POLICY/PROCEDURE
PAGE 1 OF 2
APPROVAL:
SUBJECT: RN X-ray Ordering Guidelines
RELATED POLICIES: ED Nursing Standard of Care
EFFECTIVE DATE: 4/00
REVISION DATE:1/02
Policy: The following films may be ordered independently by ED-RNs for patients with recent
extremity trauma.
General Guidelines for Extremity X-rays
If any of the following are present, an x-ray is indicated:
• Deformity
• Bony instability
• Crepitus
• Point tenderness
• Ecchymosis or severe swelling
• Mod-severe pain with weight bearing (hip, thigh, foot)
• Any penetrating injury in a joint area
• Foreign body present or suspected
Guidelines for Specific Areas
Toes/Fingers:
• Order only the involved digit if all signs/symptoms are distal to web space
• Order foot/hand for any involvement proximal to web space
Foot:
• Signs/symptoms from the web space of the toes to the bend of the ankle
• Use Ottawa Ankle Rules
• Calcaneous films may be ordered for isolated heel pain after a fall from a height where the
patient landed on the heels
Ankle:
• Use Ottawa Ankle Rules
Tibia/Fibula:
• Signs/symptoms not proximate to ankle or knee
Knee:
• Use Ottawa Knee Rule
Hand
• Signs/symptoms proximal to the web spaces of the fingers and distal to the base of the thumb

2. RN X-ray Ordering Guidelines -- Page 2 of 2 -- 1/02
Wrist:
• Signs/symptoms between web space of thumb and just proximal to the head of the
radius/ulna
• Note the presence of snuffbox tenderness on x-ray req and in nurses notes
Forearm:
• Localized tenderness or limitation/loss of supination/pronation/
Elbow:
• Pain associated with limitation/loss of supination/pronation/ extension
• Children < 5 y.o. with suspected radial head subluxation (Nursemaid’s elbow) do not require
x-rays
Humerus:
• Signs/symptoms in upper arm
Clavicle:
• Tenderness specific to clavicle
Shoulder:
• Decreased range of motion or tenderness and recent history of dislocation
Hip/Pelvis:
• Fall with hip pain, externally rotated and/or shortened extremity, unable to bear weight
Portable Chest:
• Unstable patients in significant respiratory distress or s/p intubation
X-ray Requisition
According to federal regulations regarding reimbursement for diagnostic testing, the x-ray
requisition must include the following information:
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Body part to be examined with laterality identified if appropriate
Clinical indication for the exam
History-Signs-Symptoms
What is the question we are trying to answer?
Attending MD's name (if two are on duty, list both names)
Date