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Department of Neurology Rochester General Hospital REQUISITIONS FOR EVOKED POTENTIALS (EPS) To be completely fully and legibly by referring physician Fax to Neurology Lab 585.922.7485 Patient Name:

How to fill out requisitions for evoked potentials

How to fill out requisitions for evoked potentials:

1. Start by entering the patient's personal information, such as their full name, date of birth, and contact details. This is important for identification purposes and ensuring that the results are properly matched with the correct patient.
2. Indicate the date and time of the requested evoked potentials test. This helps to schedule and coordinate the procedure efficiently.
3. Specify the type of evoked potentials being requested. There are various types, including Visual Evoked Potentials (VEP), Auditory Evoked Potentials (AEP), and Somatosensory Evoked Potentials (SEP). Provide a brief description of the symptoms or indications that warrant the need for these tests.
4. Include relevant medical history and clinical information that could impact the interpretation of the test results. This may include any pre-existing conditions, medications, recent surgeries, or other relevant factors. Providing as much detail as possible helps the healthcare provider to understand the patient's overall health status and consider potential influencing factors.
5. If the patient has any known allergies or sensitivities to specific substances or materials used during the evoked potentials test, make sure to include that information on the requisition form. This is crucial for the safety and well-being of the patient during the procedure.
6. Ensure that the requisition form is signed and dated by the ordering healthcare professional. This signifies their authorization and responsibility for the requested test.

Who needs requisitions for evoked potentials:

1. Patients who are experiencing vision-related issues may require a requisition for Visual Evoked Potentials (VEP) to assess the function of their optic nerves and visual pathways.
2. Individuals with suspected hearing problems might need a requisition for Auditory Evoked Potentials (AEP) to evaluate the conduction of sound through their auditory pathways and aid in diagnosing hearing impairments.
3. Patients with suspected nerve damage or neurological conditions may necessitate a requisition for Somatosensory Evoked Potentials (SEP) to assess the integrity and function of their sensory pathways.

In summary, requisitions for evoked potentials are required to facilitate the appropriate scheduling and performance of these specialized tests. They help ensure accurate diagnosis and treatment planning for patients experiencing vision, hearing, or nerve-related issues.

For pdfFiller’s FAQs

What is requisitions for evoked potentials?

Requisitions for evoked potentials are requests for medical tests that measure the electrical activity in the brain in response to stimuli.

Who is required to file requisitions for evoked potentials?

Medical professionals such as neurologists or doctors are required to file requisitions for evoked potentials.

How to fill out requisitions for evoked potentials?

Requisitions for evoked potentials are typically filled out by providing patient information, test details, and the reason for the test.

What is the purpose of requisitions for evoked potentials?

The purpose of requisitions for evoked potentials is to diagnose neurological conditions and monitor the function of the nervous system.

What information must be reported on requisitions for evoked potentials?

Requisitions for evoked potentials must include patient demographics, test details, referring physician information, and the reason for the test.

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