Are Clinicians Communicating adequately with Radiologists through Radiological requisition? A Clinical Audit assessing Current local practice

Abstract

Introduction: A radiological request form is the only communicating tool between the treating physician and the radiologist. An incompletely filled form may fail to provide the correct diagnosis through imaging. This study was conducted to assess the adequacy of filled radiological request forms in a tertiary health institute. Methods: Three hundred radiological requisition forms which were filled by doctors at tertiary hospital were selected randomly and analyzed. The forms were evaluated for completeness of the information entered by the physician. The request forms were selected by convenience sampling method to avoid the bias and included forms from multiple departments both inpatient and outpatient. Results: Our audit data revealed that out of the total 250 request forms that were analyzed only the names of the patients and the part to be examined was filled completely. The age and gender of the patients were filled in 99.2% and 99.6% forms respectively. 58.4% forms had relevant history written and only 16.4% form had mentioned the relevant investigations. 59.6% forms had provisional clinical diagnosis, name and department of the physician requesting the investigation were present in 75.6% and 66% forms respectively. None of the forms contained the contact number of the requesting physician with 8% forms without the name of the physician and department who had filled the request form. Conclusions: At the end of our audit, we concluded that radiological request forms are rarely filled completely which results in inadequate transmission of clinical information.

Clinical audit of computed tomography requisition form in a himalayan country, Nepal

“…Clinical information such as clinical history, clinical diagnosis, and provisional diagnosis is necessary to justify the requested examination. A similar audit carried out by Koirala A and Bhandari in a tertiary hospital in Nepal also found that none of the radiological requisition forms were adequately filled as missing clinical information was the most common finding [4]. Similarly, LMP must be noted for a female of the reproductive age group (15-49) before requesting any imaging procedures that involve ionizing radiation to prevent accidental exposure to embryo [12].…”

Clinical audit of computed tomography requisition form in a Himalayan country, Nepal

“…Inadequately filled requisition forms have been reported on similar audits carried in Nepal and in other countries [4][5][6][7]. Inadequately filled forms are prone to misleading communication that may lead to unnecessary scans and delays in the final report provided by the radiologist.…”