Adequate Completion of Radiology

Request forms

Introduction

Radiological request form is essential tool of communication between the clinicians and the radiologist and radiographers.

So inadequate information can lead to mistakes in patient identification and also delay in returning reports to the right destination, and can reduce the value of the report (Afolabi et al, 2012).

objectives

• What is the reason for this audit ?

The aim of this audit is to assess the extent of completion of each radiology request forms and to evaluate the use of frequency of filling the fields in all the forms (Akintomi et al, 2015).

Data collection method

For each request form, record the presence if not each of the items record as inadequate information forms.

50 randomly selected request forms

Location: General x-ray department

Standard

• Locally agreed standard

Radiology request form should include adequate clinical and demographic information that identifies the patient and the destination for the report.

• Target 100%

All forms should contain the following information:

• Clinical background

• The patient's name, age, address and contact number

• The name of the requesting doctor and the consultant looking after the patient name and number

• Ward

• Referrers signature

2. Findings

• 76% of request forms with adequate information.

• 24% incomplete request forms

• The most incomplete request form field was the referrers address and contacts that accounts 12%

• 6% was consultant looking after patient contacts number.

• 4% was patient's contact number

• 2% was ward number missing

• The most properly filled field of the radiology request form was clinical back ground and referrers signature, at 100%

3. Compare findings with the standard

• The actual practice did not met the standard. (100%). The main reason was that the requesting doctor full address including contact number and the consultant looking after the patient contact number was not appeared in some of the requesting forms, and this can affect effective communication among health professionals.

As, a result patient will kept waiting until the radiographers clarify clinical indications for the examination with their referrals or doctors.

Change

Suggestion

• Give notice to referrers and consultant doctors looking after the patient about the incomplete fiends of forms

• Send back request forms which are incomplete

• Request forms should distributed to all the user departments

Re-audit

• Re-audit after 6 months

Result

• Frequency distribution of adequate and inadequate RRF in percentage

Conclusion

A large number of patient's contact number and small number of consultant looking after patient's contact number were missing. This is mainly due to inadequate completion of the fields within the radiology requesting forms.