Are the CT Scan Request Forms Adequately Filled?

Abstract

Abstract

Background: Complete filling of the radiology request form is of paramount importance in helping the radiologist give concise radiological diagnoses and avoid unhelpful radiological examinations and radiation exposure. The objective of our study was to audit the adequate filling of request forms for CT scans, received at Radiology department of a tertiary care hospital.

Materials and Methods: We scrutinized the CT scan request forms received at Radiology department KTH from 20^th March-20^th June 2015. The information including patient name, address, relevant clinical history, legibility of hand writing, and identity of the referring doctors were considered as the minimum contents of the request form which were recorded in a structured proforma and analyzed via spss -16. Results: Of total 444 request forms, name of the patients was mentioned in all but address in 13% only. Clinical history was provided in 79.5%, probable clinical diagnosis was mentioned in 30%, and specific question was asked in 35%. The writing was illegible in 8.6% and non-standardized abbreviations were used in 6.5%. Renal functions were mentioned in only 1.5% of those scans requiring intravenous contrast. Referring clinician name was mentioned in 18% only, however signature was done in 89% of the request forms. Conclusion: Clinician’s practice of filling the CT scan request forms was suboptimal which needs to be improved.

Key words: Clinical audit, Radiology request form, completion, CT scan.