Adequacy of completion of radiology request forms
Journal Title: Journal of the Indian Medical Association - Year 2018, Vol 116, Issue 1
Abstract
Radiology request forms are the sole mode of communication between the referring doctor and the radiologist in a hospital setup. Their importance, however, is highly underestimated. A radiological investigation may prove fruitless if a proper clinical background and the probable conditions to be ruled out are not provided with the request1. Inadequate information can also lead to errors in patient identification and delay in dispatching reports to the correct destination, and can reduce the value of the report. Moreover the follow up of the patient’s disease process is important in the field of radiology, especially in an academic set up where correct patient identification details are precious tools. Here I set out to perform a process audit of the adequacy of completion of such request forms in Barnard Institute of Radiology, Madras Medical College, Govt General Hospital, Chennai. A representative sample of 200 randomly selected request forms2 received by the radiology department in early November 2007 was reviewed. These included requests for a variety of examinations from different departments within Government General Hospital Chennai. A database of the collected forms was created, noting which of the various fields were adequately completed. Of the 200 request forms reviewed none proved to be complete. The percentages of various fields completed were patient’s name – 84% ; patient’s age – 80.5% ; referring ward no- 72% ;IP/OP/MRD No77%; referring doctor’s signature- 79%; referring doctor’s name – 7% ; name of responsible unit chief – 19.5% ; patient’s address- 0.5%; Request given in proper requisition form - 33.5% question to be answered – 13.5; the patient’s clinical background field was filled in 38.5% forms. However these were more often incomplete and unable to fulfill their purpose. Moreover only 33.5% requests were sent in the prescribed form, the rest were in plain papers. It is quite essential to bring about a change in this practice of sending incomplete radiology request forms. The referring clinicians should concentrate on giving a detailed clinical background to derive fruitful investigations and good reports.
Authors and Affiliations
K Saneej, C Amarnath, TS Swaminathan
Keywords
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