The Project File Details
An inadequately filled radiology request form (RRF) is a common problem faced by both radiologists and radiographers. The study was designed to objectively assess the adequacy of filling of radiology request forms from two hospitals in Enugu metropolis: University of Nigeria Teaching Hospital, UNTH) Ituku-ozalla and Enugu State Teaching Hospital, (ESUTH) Parklane
Method; Radiological request forms were collected from the archiving shelves and analyzed using criteria about patient data, clinical information and referring clinician’s identity
A total number of 4158 request forms were analyzed, 2050 from the university of Nigeria Teaching Hosiptal(UNTH) Ituku-ozala and 2108 from the Enugu state university Teaching Hospital(ESUTH) parklane. Out of the total number (4158) analyzed, 3280 (78.88%) were inadequately filled by the referring clinicians while 878(21.1%) were adequately filled. 443(21.6%) were adequately filled and 1607(78.4%) were inadequately filled from UNTH while 435(20.6%) were adequately filled and 1673(79.3%) were inadequately filled from ESUTH. Conclusion; Evaluation of the radiological request form currently in use at the UNTH and ESUTH revealed the existence of important omission and mild compliance with filling of fields requested by referring clinicians.
Title page i
Approval page iii
Table of content vi
List of tables viii
CHAPTER ONE: INTRODUCTION 1
Background of the study 1
Statement of the problem 2 Objective of the study 3
Significance of the study 3
Scope of the study 4
Literature review 5
CHAPTER TWO: THEORETICAL BACKGROUND 20
Qualified medical practitioner 20
The referrer 23
Appropriate delegation 24
Referral process 24
Radiological requesting guidelines 25
Methods of radiology requesting 26
Referrers to radiology 28
Declining radiology requests 29
Electronic request 33
Choice of IT system 34
The benefits 34
Planning and implementing electronic remoter requesting system 35
CHAPTER THREE: RESEARCH METHODOLOGY 38
Research design 38
Study population 38
Sample size 38
Method of data collection 38
Selection criteria 39
Method of data analysis 39
CHAPTER FOUR: DATA ANALYSIS AND PRESENTATION 40
CHAPTER FIVE: DISCUSSION, SUMMARY, RECOMMENDATION AND CONCLUSION. 49
A radiology request form is clinical document completed by a licensed physician stating what procedure or examination is desired. This document contains what examination needs to be done, why the examination needs to be conducted and on whom the examination will be performed. Also, inherent in the radiology request form is the clinical question that needs to be answered. The clinical question can come in many forms such as ‘’what is the cause of fever and leukocytosis in this patient” or ‘’is this tumour malignant or benign” or ‘’is there a fracture?’’ though this question is not always explicity stated, it is important that the radiologist knows and identifies the clinical question inherent in the request form1. A properly completed request form is essential for proper reimbursement and to increase the efficiency of the radiology requesting process. Pertinent identifiers such as name and date of birth are necessary in a proper request from. Also a succinct and adequate clinical history is needed for the radiologist to make the proper clinical diagnosis and for the health care provider to be properly reimbursed.1
Radiology request forms are essential communication tools used by hospital and doctors referring patients for radiological investigations. However, their importance is highly underestimated2,6
Request form should be completed accurately and legibly to avoid any misinterpretation. The clinician is required to state the reason for referral as this helps radiologist to better understand the patient’s condition so that the required expertise may be utilized to proffer the necessary information to aid appreciate patient management3. In a large percentage of patients, radiology request forms play pivotal role in both diagnosis and treatment, central to this is the adequate completion of the radiology request forms. Unfortunately, most request forms encountered by radiographers in diagnosis room are inadequately filled by the referring clinician4. Choosing the appropriate investigation at the right time and providing correct biographic and clinical information of the patient is the responsibility of the clinician or medical practitioner requesting for radiological investigation2. The assessment of adequate filling of request form by the referring clinicians is the aim of the study. 1.2 STATEMENT OF PROBLEM
1.4 SIGNIFICANCE OF THE STUDY
1.5 SCOPE OF THE STUDY
The study assessed request forms sent to radiology department in two Government owned hospital in Enugu metropolis which included University of Nigeria Teaching Hospital Ituku-Ozalla (UNTH) and Enugu State University Teaching Hospital (ESUTH) for adequacy of information, for a period of one year (from January –December, 2012)s
Radiology request forms acts as vehicle that convey information from the doctor referring patient for radiological investigations. It plays pivotal role in patient diagnosis and treatment. Its importance extends to various departments in hospital not only in radiation medicine department. There is no doubt, the importance of request form cannot be over-emphasized as it reduces the number of unhelpful radiographic examinations performed and aids concise radiological diagnosis. Therefore, clinicians referring patient should adhere strictly to the Royal College of Radiologists guideline which stipulated that request forms should be adequately and legibly completed to avoid any misunderstanding that may arise.3
No standard format for radiology request forms is available, different organizations use their own personalized version. The prevalence of inadequately completed radiology request forms is considered widespread, hence, many research studies have been done in this area and some are as bellow.
Irurhe et al2 carried out a study on compliance rate of adequate filling of radiology request forms. The study covers request forms from various departments, 300 request forms were assessed. From the result, the commonest blank fields were relevant previous operation (96.7%) and mobility status of the patients (79.3%). The field for provisional diagnosis was blank in 10% forms.
Referring doctor’s name and signature were missing in four (1.3%) and seven form (2.3%) respectively. Clinical notes were missing in 13% of the forms. Date of referral was missing in 8% of the request forms. Patient’s locations and address were missing in 21% and 261 (87%) respectively out of the 300 forms analyzed. The sex and age of the patient were given in most cases 99.7% and 98.0% respectively. Evaluation of the radiological request form currently in use at the LUTH revealed the existence of important omissions and mild compliance with filling of fields requested by referring clinicians. Afolabi et al4 carried out study on the audit of completion of Radiology request form in a Nigeria specialist hospitals. Two hundred and two (202) request forms were analyzed. All the request forms had surname and other name(s) except one, however 180 (89%) of the total request form analyzed had complete information on it while 22 out of 202 did have incomplete information. Six (37%) did not have date of request on it, address were written on (39.6%). 139 (68.8%) had the ward filled on the request form. 113 (55.9%) did not have the age of patient filled properly. Majority of the request form had inscription of adult in 46% and children in 4%. No information about sex in eight (8) of the request forms. 63(31.2%) did not have specific part of body to be investigated written on the request form. 10.4% had no clinical information. Adequate information on history of pervious X-rays was volunteered in 72(35.6%) of the request form and only 6(3.0%) indicated that the film was sent along with the request form to the radiology department. Only 12 (5.9%) had previous X-ray number filled. 188(93.1%) had the name of consultant in charge of the patient. Majority 180(89.1%) had names and signature while 7(3.5%) had only names without signature and 14(6.9%) had only signature without names. In conclusion, the radiological investigation forms are still inadequately filled. There should be increasing awareness of referring clinicians through repeated continue medical education in conjunction with the radiologists and the need for regular clinical-radiological meeting.
Adegoke et al5 further looked into completeness filling of laboratory request form. 2115 request forms were analyzed. Hospital number and patient date of birth were given in 2021 (95.6%) and 182 (86.4%) respectively. However all forms recorded patients names. The consultant in charge was stated in 2043(96.6%) and none had any contact information. The requesting physician detail was also recorded in 2023(95.7%) of forms. Working diagnosis was indicated in 1972(93.2%) of forms
but no remark about current therapy. While 2058(97.3%) of all forms were legible, diagnosis was fully written in 1949(92.2%) of forms. The type of specimen was noted in 1902(89.9%) of request forms. Whereas 771(36.5%) recorded the date the sample was collected. Only 218(10.3%) did specify the time of sample collection.
In recommendation, some ways to improve the quality of data provided with each request would be to ensure accuracy of information provided by way of auditing the request forms before it is presented to the laboratory.
Ruben et al6 carried out study and found that out of 200 radiology request forms analyzed only 8(4%) were completed in full. Only the patient’s name and surname, the referring doctor’s signatures were present in all forms and the responsible consultant’s name was evident in 182. The patient’s full address was provided in 154 forms, the referring doctor’s name in 67 and the patient’s age in 58. A specific question to be answered was only encountered in 50 forms.
Ruben et al6 equally maintained that instructions should be passed to radiological staff to return any inadequately completed forms at a stage before these are actually recorded in the departments database. Returning of request forms is to be done with great care in order to avoid any unwanted delays of urgent examinations and above all any patient suffering, whilst ensuring practice6 Edeghonghon and Rebecca7 carried out an audit study in request forms submitted to the haematology laboratory between January and April, 2010. Each request was assessed for adequacy of information supplied. Three thousand request forms were studied. Out of all the required information only the patient’s names and the laboratory test being ordered were present on all 3,000 forms. The patient’s age and location were missing in 769(25.6%) and 1433(47.8%) forms respectively. Patient’s gender was present on 67.3% of the forms. Only 77.3% of the request forms evaluated contained the clinical details of the patient. With respect to physician information; the name of the physician ordering the test was provided on 55.4% of forms, while 75.7% were signed by the doctor. The date the test was ordered was present on 62.7% of forms. None of the 3,000 request forms had the requesting physician’s telephone number or the time the specimen was collected. Edeghonghon et al7 further stressed that closer interaction between laboratory personnel and clinicians should encouraged and the laboratories should be more closely involved in organizing orientation programs for newly employed doctors, especially pre-registration house officers.
Agwu et al8 did a study to evaluate the efficiency of completion of request forms by referring clinicians and the utilization of radiological service by clinical unit in University of Nigeria Teaching Hospital (UNTH), Enugu. 8500 request forms were reviewed. Referring clinicians supplied no information about patient age and sex in 42% (N = 3500) of the cases. Part of the body to be examined was not stated in 40% of the cases (N = 3400) and the dates the requests were made were not indicated in 30 %( N=2550). The general out-patient department (GOPD) and the Internal medicine department utilize radiological services most and jointly constituted 52% (N =4420) of the total request made. It revealed the existence of important omissions and poor compliance with filling of important information.
In retrospective study done by Annalise et al9, he maintained that 68.2% of laboratory error is due to pre-analytical error in which completion of request forms is the most influencing factor. In the course of the study, 482 request forms for thyroid function tests (TFTs) were reviewed, it was found out that the worst parameter completed by requesting clinicians was that of medication details, 359(74.5%) of the forms lacked this parameter; 349(65.2%) had no contact details for the clinician; 100 (20.8%) had no diagnosis and 122(25.3%) had a diagnosis but in an abbreviated form. The type of specimen collected was not stated on 16(3.3%) of forms 36(7.5%) did not state the date and 175(36.3%) did not state the time of collection. The study shows that laboratory request forms received from primary care clinics and regional hospitals are also inadequately completed.
An important element in the multidisplinary approach to patient management is communications among clinicians11
Adebayo et al11 assessed 600 radiological request forms of availability of clinical information and demographic data. It was found that names of the patients was provided in almost all the request forms except one, a victim of road traffic accident who was unconscious at presentation. Result also showed that clinical information, age, hospital number, physician identify was not provided 18.5%, 20.8%, 39.9% and 8.7% respectively. Information on consultant -in- charge was not include in 11.3%, while 84.2% showed no information on previous radiological examinations. Only 4.8% of the forms were completely filled leaving 95.2% uncompleted. Adebayo recommended that radiology departments should be involved in the orientation programs for new house officers and resident doctors to let them know the importance of various items on the request forms.
Neelam et al12 examined a total of 1513 request forms received at there laboratory during a 3 months period. The forms were scrutinized for the presence of specific parameter to assess the pre-analytical errors affecting the laboratory results. No diagnosis was provided on 61.20% of forms. Type of specimen was not mentioned in 61.60% of the forms and 89.25% of all forms were illegible. And 76.60% were not communicated due to incomplete forms. The name of the patient was recorded in all the forms whereas their age was not mentioned in 1.41%, sex of the patients was not mentioned in 1.32% and the registration number was missing in 0.99% of the patients. The details pertaining to whether the patient had been registered at the OPD, Ward, ICU or Emergency was missing in 3.6% of the forms. Of these abbreviated diagnosis nearly 6.6% were not standard abbreviations12
Philip et al13 equally stressed that abbreviations often cause confusion, he added that to prevent errors and misunderstanding, referring clinicians and radiologists must show more restraint when using abbreviation13
Strilpi14 said errors occur due to ambiguities in cases like TOF (Tracheoesophageal Fistula or tetratology of fallot PID (Pelvic inflammatory disease or prolapsed intervertebral disc). In his work, he also found out that around 10,000 medical abbreviations exist, with about 16,000 different meanings.
To prevent harm to the patient, it is vital to ensure that the intended meaning is clear14
No wonder, royal college of radiologist guideline (RCR) stated that forms should be complete accurately and legibly in order to avoid any misinterpretation3. You should states clearly the reasons for the request and give sufficient clinical details to enable the imaging specialist to understand the particular diagnostic or clinical problem that you are attempting to resolve by radiological investigation.3,14
Jumah et al15 carried out prospective study in Ghana, Sierra Leone and Nigeria. The aim was to highlight to the clinicians the common faults encountered in radiological request forms and to make recommendation aimed at improving information given on such forms which will facilitate better reporting by radiologist. 4,122 request forms from the three institutions were reviewed using questionnaire and analyzed. The common fault was omission of the age of the patients; this occurred in 1,176 cases. Absence of clinical information in the request forms was noted in 946 cases and illegible entries were 658. There were 65 unconventional abbreviations used by clinicians on request forms. There should be regular clinic-radiological meetings as continuing medical education for hospital doctors and general practitioners and also vetting of request forms for specialized radiological examinations to reduce the short coming.
Rachael et al16 conducted a study to assess the adequacy of filled request forms in a tertiary health institution. One hundred and forty four (144) with 145 requests for computed tomography scan (CT scan) and Magnetic Resonance imaging (MRI) received at the diagnostic centre in a teaching hospital were studied for completeness. There were 138(95.2%) CT scan and 7 (4.8%) MRI request, only the surname and examination request were filled in all cases. About 95.8% of the addresses were not filled. Although patient’s ages were provided in 90.3% of cases, 74 (57.0%) of them were only written as figures. Though clinical history was given in almost all patients, only 26(18.2%) were detailed. Abbreviations which are not universal acceptable were used in all the forms. Rachael stressed that radiological request forms are often inadequately filled and as such, clinicians should be educated on the value of correctly filling request form.
Triantopoulou ch et al17 evaluated the adequacy of patient data and clinical information transmitted to the radiological departments by the referring clinicians in conjunction with justification of X-ray exposures.
1708 request forms of patients referred to radiology department and 410 referred to the CT department were analyzed. Omissions were more prominent for the referrals to the radiology department, where the age and the probable clinical diagnosis were not given in 81.5 and 46% of the forms, respectively. Furthermore, the emergency indication was less cautiously used compared to the CT requests. For the CT department, 33.3% of requests were justified and the final diagnosis was included in the referring doctor’s probable clinical diagnosis. Ultrasound was the examination of choice in 51% of the cases where an examination should have performed before CT and in 70.6% of the cases where an alternative examination was proposed. The large number of not fully justified CT requests observed in this study is typical example of problem that radiologists have to face in order to apply the justification directives.
Judy et al18 conducted a study to determine the impact of referral (compared with paper- based referrals on specialty referrals) on specialty referrals. 505 questionnaires were collected from specialty clinicians. It was difficult to identify the reason for referral in 19.8% of medical and 38.0% of surgical visits using paper-based methods when compared with 11.0% and 9.5% of those using eReferral. Of those using eReferral, 6.4% and 9.8% medical and Surgical referrals using paper methods versus 2.6% and 2.1% were deemed not completely appropriate. Fellow-up was request for 82.4% and 76.2% of medical and surgical patients with paper-based referrals versus 90.1% and 58.1% of eReferrals. Follow-up was considered avoidable for 32.4% and 44.7% of medical and surgical follow-ups with paper-based methods versus 27.5% and 13.5% with eReferrals. Finding suggest that eReferrals may be an effective way to prevent inappropriate referrals from resulting in appointments in surgical clinics, thus saving unproductive visits.
Dhinagsa et al19 did work on whether a radiation exposure is justified and whether a request conforms to the Royal College of Radiologists (RCR) guidelines. Three GPS and three consultant Radiologists were asked to review 100 requests for plain film imaging. Out of the 100 requests, only one (1) did not contain enough clinical information for all six reviewers to decide whether exposure should be made.
Only 16 of the 100 request forms were justified by all six reviewers.
4 of the 100 request were considered “not justified” by all six reviewers
50 of the 100 requests were justified by all three General practitioner (GPs), however, only 16 of these were justified by all three radiologists, with 6 not justified by any of the 3 radiologists.
All six reviewers felt that 11 of the 100 requests conformed to RCR guidelines and that 9 request did not.
40 of 100 cases at least one of the six assessors felt the request was not covered in the RCR guidelines.
Moudgil et al20 and his correspondent looked into improving communication between the ophthalmology and histopathology department at royal Hallamshire Hospital, Sheffield, by effectively changing the structure and completion of the histopathology request form through the process of a successful audit.
On the basis of audit results of 710 histopathology request forms, a new histopathology request form was created which was easier to complete. Review of the 224 new histopathology request forms showed improved percentages of completion of important sections of the form. The filling out of essential information such as contact details of the operating doctor was improved to 82.5%, having been missed in 50% of the initial forms. More modest, but evident improvement in filling out of “Referring consultant’’ (80.1-99.6%) and “operating doctor” (85.6-95.9%) were also seen. Date taken, significantly improved from 60.4% to 93.0%. Filling of laterality increased to 98.0%, which on the initial form was perhaps unexpectedly low (at 88.2%). In conclusion, careful structured request form and increasing awareness amongst users can help to improve filling of request forms.
Bankole et al21 conducted a study to determine type and frequency of omission of relevant data on laboratory request forms. A total of 2,362 laboratory request forms sent to the pathology department of Igbinedion University Teaching Hospital Okada were scrutinized for specific parameters. Information regarding patient’s age, gender and location (ward) was missing in 48.3%, 1.1% and 20.1% respectively of all forms evaluated. There was no provision on the laboratory form for telephone number of the attending clinician. The name of attending clinician was not documented in 19.8% of laboratory request forms. The type of sample was not documented in 2.7% of forms audited. Sample collection data and type of test of test required were not supplied in 5.6% and 1.5% respectively of all forms evaluated. A total of 151(6.4%) of forms did not carry information on the working diagnosis. The patient’s name and signatures of attending clinicians was observed on all forms. Patent’s age and location were mostly omitted; the relevance of completeness of data on laboratory request test forms is strongly advocated
Muhammad et al22 did work to ascertain the adequacy of information provided by clinicians when requesting a histopathology investigation, the study was carried out at Armed Forces Institute of pathology in December 2006. Out of 500 specimens, age was not mentioned in 29(5.8%) cases. No clinical history or differential diagnosis was given in 170 (34%) cases. Site of biopsy was absent in 65(13%) cases and the name of requesting clinician or any contact information was present in only 115(23%) of request forms. Clinicians of all grades and specialties must be educated and made aware of their primary responsibility to request the investigations appropriately for the benefit of the patient and patient care.22
JL Burton and TJ Stephenson23 carried out study to determine the adequacy of information provided when histopathological investigations are requested. Two thousand sequential requests were assessed; there was no significant difference in the demographic details supplied by physicians and surgeons. Clinical detail were inadequate in 6.1% of cases: those from physicians were significantly more often adequate (98.7% v 90.6%) and more often include a diagnosis (74.4%) v 38.8%) than those from surgeons. physicians were more likely to supply their name and contact number but requests frequently lacked details of the sender.
Bassey et al24 conducted a retrospective study reviewing pathology requisition forms accompanying endometrial curetting submitted to the histopathology department of university of Calabar Teaching Hospital (UCTH) from Jan. 2004 to Dec. 2007. Each request form was analyzed for presence and completeness of clinical information. Out of a total of 126 cases of endometrial curettings studied, the most consistently provided information was age of patient (100) while the least provided information was contraceptive/ hormonal history of patient (0.8%). Relevant clinical history such as contraceptive/hormonal history which has a direct bearing on interpretation of endometrial curetting was sadly lacking in a great majority (99.2%) of cases. Clinicians need to be made aware of their primary responsibility to request histopathological service appropriately for the benefit of the patient.24
Nutt et al25 studied request forms received for the presence of specific parameters. A total of 2580 request forms were analyzed. Medication(s) used by the patient (87.6%) and doctor’s contact number (61.2%) were the most incomplete parameters. No diagnosis was provided on 19.1% of forms and when a diagnosis was present it was an abbreviated form in 37.3%. This resulted in 35.5% of diagnosis not being recorded by reception staff. Incomplete ward information was found on 4.9% of forms. As laboratory data influences 70% of medical diagnosis, incorrect or incomplete data provided to the laboratory could significantly impact the success and cost of overall treatment25