ASSESSMENT OF ADEQUACY FILLING OF RADIOLOGY REQUEST FORM BY REFERRING CLINICIANS

ABSTRACT
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.         
TABLE OF CONTENT
Title pagei  Dedication ii Approval pageiii Certificationiv Acknowledgementv Table of contentvi List of tablesviii Abstractix CHAPTER ONE: INTRODUCTION1 Background of the study1 Statement of the problem2   Objective of the study3 Significance of the study3 Scope of the study4 Literature review5 CHAPTER TWO: THEORETICAL BACKGROUND20 Qualified medical practitioner20 The referrer23 Appropriate delegation24 Referral process24 Radiological requesting guidelines25 Methods of radiology requesting26 Referrers to radiology28 Declining radiology requests29 Electronic request33 Choice of IT system34 The benefits34 Planning and implementing electronic remoter requesting system35 CHAPTER THREE: RESEARCH METHODOLOGY38 Research design38 Study population38 Sample size38 Method of data collection38 Selection criteria39 Method of data analysis39 CHAPTER FOUR: DATA ANALYSIS AND PRESENTATION40 CHAPTER FIVE: DISCUSSION, SUMMARY, RECOMMENDATION AND CONCLUSION.49 Discussion49 Summary52 Recommendation53 Conclusion53 Reference 55 LIST OF TABLES
Table 1a: Distributions of patient bio-data information inadequately completed by referring clinicians in UNTH. Table 1b: distributions showing clinical information inadequately filled by the referring clinicians in UNTH. Table 1c: distributions showing ancillary information not completed by the referring clinicians in UNTH Table 2a: distributions of patient bio-data information that inadequately completed by referring clinicians in ESUTH. Table 2b: distributions showing clinical information inadequately filled by the Referring clinicians in ESUTH Table 2c: distributions showing ancillary information not completed by the referring clinicians in ESUTH Table 3: distributions showing the number of adequately and inadequately filled request forms by various clinicians in UNTH. Table 4: distributions showing the number of adequately and inadequately filled request forms by various clinicians in UNTH. Table 5: comparison between adequately filled request forms in UNTH and ESUTH
INTRODUCTION
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.