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Jun 14, 2016Keywords:
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A simple audit of radiological request forms at the University of Port Harcourt Teaching Hospital
Abstract
Background: Radiological investigations are often essential in the management of patients. The request forms act as a medium between the managing Physician and the Radiologists who is often required to make significant input. Failure to properly complete these forms may therefore result in misdiagnosis and possible mix-up of the forms. We therefore, undertook to document the extent to which radiological request forms are properly filled.
Methods: Three hundred radiological request forms which had already been filled out by doctors at the University of Port Harcourt Teaching Hospital between January and June, 2014 were randomly selected and analyzed. The forms were evaluated for completeness of the information entered by the clinician.
Results: The names of the patients and the requested investigations were fully entered on all 300 forms. However, all other criteria were not fully completed. The ages of the patients were filled in properly on 259 (86.3%) forms, while 13 (4.3%) did not record any age. The date on which the investigations were requested was filled on 294 (98.0%) of forms. Four (1.3%) did not fill in any date while it was incompletely filled in 2 (0. 7%). Also, the sex of the patient was filled on only 292 (97.3%). The required clinical information of the patient was recorded in 275 (91. 7%) of forms. One (0.3%) did not give any clinical information while 24 (8.0%) forms did not have adequately filled clinical information. Also, the name of the requesting doctor was filled in 273 (91.0%) forms while 27 (9.0%) forms did not have the name of the requesting doctor. The requesting doctors signed in 273 (91.0%) forms while 27 (9.0%) did not carry any signature. The name of the Consultant Surgeon was recorded in 244 (81.3%) while 56 (18. 7%) did not have the Consultants' names.
Conclusion: Radiological request forms are not always filled out properly. Only the names of the patients and the required investigations were properly written.
Keywords: Radiological request; forms completion; audit
