Completeness of radiology request forms in a Johannesburg Paediatric Hospital

Abstract

INTRODUCTION: Radiological request forms are currently the main written tool used for booking any imaging modality and are a vital communication tool between the clinicians and the radiology department. This not only gives information about the patient’s biodata, clinical and medical history but also determines what imaging modality should be done, based on the case. Thus, the importance of complete and proper information from the booking clinician cannot be overemphasized as this may lead to unnecessary radiation, examination, and costs to name a few. AIM: This research aims to evaluate the completeness of radiological request forms from Nelson Mandela Children Hospital METHOD: Five hundred request forms were obtained and analysed retrospectively. The forms were derived from 4 different modalities. 200 Plain film; 100 MRI, 100 ultrasound and 100 CT. Participating departments included but were not limited to, Cardiology, Paediatrics, Paediatric surgery, Neurosurgery, ENT, Orthopaedic, etc. RESULTS: Only 2,6 % (n13) of the forms were deemed fully completed by the stipulated standard. The completeness rate analysis, however, revealed variability across departments and modalities. Overall completeness rate was 75% on average across all modalities, with the highest overall completeness rate observed in Plain film (77%), while MRI showed the lowest (73%). Departments such as NICU, Cardiology, and PICU consistently exhibited higher completeness rates, while Neurosurgery and Orthopaedics had lower rates. Patient’s demographic scored the highest (100% average) amongst all modalities whilst ‘previous relevant imaging’ and ‘additional relevant history’ scored the lowest (21 % average) amongst all modalities. 6 CONCLUSIONS: Radiology request forms completion remains incomplete across various modalities and departments, and this may lead to miscommunication amongst radiologists and referring clinicians as this is the main tool for communication and a decisive factor for imaging. Potential consequences can include over scanning, thus over exposure to ionizing radiation, which is especially detrimental to the paediatric population.