MRI Zone IV Safety Screen

Pre-entry safety inspection for MRI Zone IV to identify ferromagnetic implants, conditional devices, pumps, and external aids before access is granted.

Screening Context and Identity

• Person being screened identified and role confirmed
  Record the name or identifier and whether the person is a patient, visitor, or staff member.
• MRI Zone IV access requested for this entry
  Confirm this screening is being completed immediately before Zone IV access.
• Screening completed by authorized MRI personnel
  Confirm the screener is trained and authorized per facility MRI safety policy.
• Current MRI safety screening form or protocol used
  Enter the form name, version, or protocol reference used for this screening.
• Any uncertainty escalated to MRI safety officer or radiologist
  Use when implant, device, or history details are unclear or incomplete.

Implants, Devices, and Conditional Equipment

• Presence of ferromagnetic implants or foreign bodies screened
  Confirm screening for aneurysm clips, shrapnel, bullets, metallic foreign bodies, cochlear implants, neurostimulators, and other ferromagnetic implants.
• MRI-conditional implant/device status verified against conditions of use
  Verify any MRI-conditional implant or device is permitted only within the exact manufacturer conditions, including field strength, SAR, positioning, and monitoring requirements.
• Implant or device make/model and MRI conditions documented
  Record the device name, manufacturer, model, and any applicable MRI conditions or restrictions.
• External or removable medical devices removed or approved for Zone IV
  Confirm items such as insulin pumps, infusion pumps, transdermal patches with metal, hearing aids, prostheses, wheelchairs, walkers, and monitoring devices are removed or specifically cleared for MRI entry.
• Battery-powered or electronically controlled device screened for MRI compatibility
  Confirm any battery-powered or electronically controlled device has been checked for MRI safety status before entry.

Personal Items, Clothing, and External Aids

• All metallic personal items removed
  Confirm removal of keys, coins, phones, jewelry, watches, credit cards, pens, hairpins, piercings, and other metallic objects.
• Clothing screened for metal fasteners, wires, or conductive materials
  Verify clothing is MRI-safe and free of zippers, snaps, underwire, metallic threads, or other conductive components.
• External aids removed or approved
  Confirm removal or MRI clearance of glasses, dentures, wigs, hearing aids, orthotics, braces, and similar external aids.
• Wheelchair, stretcher, or mobility aid checked for MRI compatibility
  Verify any mobility aid entering Zone IV is MRI-safe or MRI-conditional and free of unsecured ferromagnetic components.

Monitoring, Pumps, and Life Support Equipment

• Infusion pumps, syringe pumps, and IV poles screened before entry
  Confirm pumps and poles are MRI-safe/conditional or removed from Zone IV as required by facility policy.
• Monitoring equipment screened for MRI compatibility
  Verify pulse oximeters, ECG leads, blood pressure equipment, and other monitors are MRI-safe or MRI-conditional for the planned scan.
• Oxygen cylinders, tanks, and related accessories screened
  Confirm oxygen delivery equipment is MRI-compatible and secured according to MRI safety requirements.
• Emergency support equipment available outside Zone IV as required
  Confirm emergency equipment needed for the patient is staged in the appropriate non-magnetic location per facility protocol.

Clearance, Exceptions, and Final Authorization

• Any prohibited item or unresolved concern present
  Use this item to capture any unresolved implant, device, or external aid concern that would prevent safe entry.
• Exception approved by radiologist or MRI safety officer
  If an exception is allowed by policy, document the approving authority and any restrictions.
• Zone IV entry authorized
  Confirm the person may enter MRI Zone IV based on completed screening and any required approvals.
• Inspector signature
  Signature of the MRI staff member completing the pre-entry safety screen.