Adequacy of clinical information on radiology request cards from medical admission unit

Mohamed Abbas

Adequacy of clinical information on radiology request cards from medical admission unit

Mohamed Abbas

James Cook University Hospital, UK

: J Diagn Tech Biomed Anal

Abstract

Background: The easiest and best way of communication between the clinician and radiologist is the radiograph request form. Requests should be completed accurately and legibly to avoid any misinterpretation. In our practice, we have noticed that radiology request cards sometimes do not contain enough information. There is evidence that inadequate clinical information is associated with an increased level of inaccurate reports. Standard: All submitted radiology request forms should contain adequate information. Methods: 150 radiology request forms have been selected including X-ray, CT scan and Ultrasound scan requests. Data items collected respectively were: 1) clinical information provided in form of brief clinical history, brief clinical examination findings and/ or other investigation findings 2) question to be answered and 3) identifier for the person making the request. Results: In total, there was relatively low interest in providing contact detail on the cards (79.3%). Clinical information in terms of brief history and relevant clinical examination were deficient generally in all request forms (only 82.7% provided relevant history, 90.7% which provided relevant clinical examination findings, and only 90% provided the provisional diagnosis or the question need to be answered). We also noticed that doctorsÃ¢Â€Â™ practice in providing the needed information varies with different radiological studies. Improvement: What actually happened is we recommended adding e-requesting to our system. We had great support from hospital consultants and mangers. Now we have e-requesting for all radiological studies with important fields starred so that requests wonÃ¢Â€Â™t be submitted without those fields completely filled in.