Incomplete Patient Data on Chemical Pathology Laboratory Forms in a Tertiary Hospital in Nigeria

Abstract

Background: Correct and complete filling of information on the laboratory request forms is necessary if preanalytical errors are to be minimized. It also gives the laboratory opportunity to compare results with the clinical details of the patient, which can point out the possibility of errors in either laboratory test or clinical diagnosis. Appropriately, filled laboratory forms allow for timely communication of critical results to physicians providing early intervention and improved patient care. We, therefore, evaluated the extent of incomplete laboratory forms in our center. Methodology: The study was a cross‑sectional where assessment of forms received over 3 months from February 17, 2014, to May 28, 2014, in the Chemical Pathology Department of Federal Teaching Hospital, Gombe, during working hours were analyzed for the frequency of incomplete data. The forms were scrutinized for the presence of name, gender, age, clinical details, ward/clinic, consultant, hospital number, and doctor’s signature. Results: Only 8% of a total of 4638 forms provided all the required data. Only patient’s name appeared in all the forms. Time of sample collection (58%) was the most omitted parameter. Age and gender did not appear in 39% and 38%, respectively. No clinical details or location of the patient was provided in 25% and 24% of the cases. Consultant in charge was missing in 38% of forms. Date of request, doctor’s signature, and hospital number were missing on 18%, 18%, and 13%, respectively. Conclusion: The study has demonstrated high frequency of incomplete information needed on the laboratory request forms. This may be responsible for many preanalytical errors. Increased interaction between clinicians and pathologist with a view to reducing the frequency of preanalytical errors should be encouraged.