Standardized Provincial non-MRI Requisition
Effective: August 13, 2025
Background Information:
Shared Health Diagnostic Services has developed a standardized Requisition Form to be used to request X-Ray/Fluoroscopy, CT, Ultrasound, and Nuclear Medicine examinations at facilities not affiliated with DI Central Intake (SH-SS, Brandon/PMH, IERHA, NRHA, and Churchill) referred from across Manitoba. This requisition has been set up by the Provincial EMR Support Services in their system.
Requesting XR, CT, US, NM outside Winnipeg at sites NOT on DI Central Intake
Effective immediately, all urgent and elective XR, CT, US, and NM requests for facilities outside Winnipeg must be submitted using the new Request for Diagnostic Imaging Exam (Rural) form R250-10-116 and directed to the nearest Diagnostic Imaging department for triage. This change is intended to improve scheduling efficiency and reduce delays for rural patients. You may still indicate a preferred site. If you’ve consulted a radiologist, note their last name and site on the requisition (top left, Outpatient section). Emergent and inpatient requests must continue to be arranged directly with the on-site radiologist.
Requesting XR, CT, US, NM in Winnipeg (sites on Central Intake)
The current request form called “Request for Diagnostic Imaging Exam XR, CT, US, NM” (SAP #299189) used to request DI exams at Winnipeg facilities affiliated with Central Intake remains in effect. This request form is also for referring patients from other areas in the province to facilities in Winnipeg.
Requesting Mammography and Echocardiography across Manitoba
Please use “Manitoba Provincial Breast Imaging Request Form” and Adult Cardiology Program Echocardiography Request to refer patients for Mammography and Echocardiography exams.
Actions Required
- The Provincial EMR Support Services have built the new requisition form into their system. The Form is available in .PDF format for downloading from the Shared Health website for facilities that don’t have an EMR.
- Please discard printed and saved electronic copies of older Diagnostic Imaging requisitions.
- The Relevant Clinical/Surgical History section MUST be completed and include relevant clinical history AND if applicable, surgical history. It should never be blank. Radiologists rely heavily on the clinical history to determine priority, scheduling and protocoling of each case.
Changes to Request for DI Examination (Rural):
- The Winnipeg local and toll-free fax numbers for Central Intake have been removed.
References/Resources:
Access the Request for Diagnostic Imaging Exam (Rural) form instructions
Submitted by: Tamara Burnham, Collaborative Practice Lead