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 Introduction

In today’s medical practice, imaging plays a major role in patient management with the ready availability of revolutionary technology. However interpretation of the results depends on the background knowledge of the patient. The reason and justification for the investigation should be indicated on the request form. This input is essential to the radiologist from the clinician. Though there are no uniform standard request forms, each hospital adapts its own version suitable for appropriate referral. Inadequate or incomplete information on the request form takes away much of the time of radiologist in searching or imagining the clinical condition of the patient. Besides the full demographic data of the patient such as the name, age, sex, address including the telephone number, date, the form should show the name and signature of the referring physician. This is helpful to contact the physician for discussion on the clinical issues and even to locate the patient if not yet shifted to the imaging department. Guidelines from American College of Radiology and Royal College of Radiology are available for adaptation and standardization in order to give less unhelpful results and reports and to deliver health care more efficiently.

Material and methods

Two hundred request forms (100 each for CT scan and MRI) received over a period of 2 months were selected randomly. Patient’s demographic data, Physician’s name and signature, date of request and location of the patient in the hospital were tabulated (Table 1). In addition, clinical diagnosis and extent of clinical details were also compiled in a tabular form (Table 2). Adequacy of clinical data was recorded as absent, inadequate, adequate and excellent for image interpretation.

Table 1: Demonstrates the unavailable demographic data of 200 patients in the request forms.

Table 2: Unavailable data from 200 request forms for CT & MRI Scanning

Results

A total of 200 randomly selected request forms for CT scanning and MR imaging were analyzed. They comprised 100 each for CT Scanning and MR imaging. There were 105 from outpatient and 95 from the in patients. Tabulated results revealed inadequate data in many fields. Location of the patient was not mentioned in 160 request forms (80 %). It was not possible to identify exact location of the specific ward or OP or ICU from the forms though the OP request cards had an identity. A small number of requests were written on cards or in progress sheets. Two requests were sent on the physician’s letter head. Another two requests were received on plain paper slips. There was no clinical diagnosis in 84 forms (42 %). Clinical details were not provided in 124 forms (62%). Good clinical history was provided in 11 forms only (6 %) (Table 3). Patients’ age and sex were not mentioned in 71 request forms (35 %). Physician’s signature was not found in 109 forms (54 %). These forms were however signed by the nursing staff (46 %). Name of the referring physician and date of request were not mentioned in 11 forms each (6%). Illegible writing was noted in 20 % of the forms. Ambulatory status and information on previous radiographs or previous reports were not mentioned in any form. Telephone numbers of the wards and ICU were given in 39 request forms (20 %).

Table 3: Clinical details in 200 request forms.

Discussion

Incomplete and inappropriate requests for radiological investigations is a wasted exercise and creates scope for error with resultant unnecessary repetitions and radiation to the patient. Literature survey reveals a large number of studies addressing adequacy of filling of radiology request forms [1-4]. Common faults in filling the requisition forms were analyzed by Jumah et al and recommended necessary steps to correct [5]. With the growing concern for increasing radiation exposure, compliance rate and justification for the requests were audited in University Teaching Hospitals and General Practitioner referral patterns [6, 7]. Adequacy of clinical information from accident and emergency (A&E) department was audited by the Royal College of Radiologists Research Group [8].

While evaluating the quality of radiology requisitions for intensive care unit patients Cohen et al noted shortcomings in documentation and communication resulting in poorer outcomes [9]. It is also observed in almost a third (30%) of all radiological requests were made by doctors who have had no clinical contact with the patient and as such, there is a real risk that standards of patient care and safety have fallen [10].

Of the 200 forms audited in the present study, clinical diagnosis was not available in 84 forms (42 %) and there were no clinical details in 124 forms (62%). About 20 % of forms are illegible. Physician’s signature and patient’s location in the hospital were not mentioned in more than 50 % of the requests. It necessitates the radiologist to search for the required clinical information from bulky patient file which is not only time consuming but also a vain exercise often. Often the progress sheet is not in the serial order in the file and the physician concerned is unknown to be contacted over telephone. The problem is compounded by unavailability of previous imaging investigations. It is a common practice to send the patient for immediate Ultrasonography or CT scanning from the Accident & Emergency before clinical details are written in the file.

The referring physician may address the need and timing of the investigation. Sometimes he or she may realize the investigation had been done already from another hospital or Outpatient or A & E. It is prudent for the clinician to ask himself if the problem was clearly expressed in the form and to confirm with the radiologist if this is the best investigation. Patient may not get what you request if appropriate clinical information is not given or a wrong investigation is asked for. An anticipated positive finding on imaging may be clinically or therapeutically irrelevant, for example a fracture of rib or degenerative spinal disease and the investigation will be of no consequence.

From the observations in this study, a need to redesign the request forms was felt in order to obtain relevant information from the clinicians. Reject Request Form philosophy should be implemented to improve the referral pattern as per acceptable norms and standards. It would be possible by scrutinizing the request forms by an experienced radiologist before accepting for the investigation.

In the interest of patient safety, the department of health, UK Government has issued clear guidelines regarding the requesting of radiological investigations. The legislation, ‘Ionizing Radiation (Medical Exposure) Regulations (IRMER) states that when requesting a radiological investigation, the referrer (clinician) is required to provide sufficient and accurate clinical information for the IRMER practitioner (radiologist/radiographer) to be best able to determine whether the examination is appropriate and justified [11]. This clearly states that the referrer (Clinician) has a responsibility to provide accurate and necessary information to the radiological practitioner, who is then responsible for determining if the request is appropriate. It is therefore clear that the referrer must have sufficient data regarding the patient to ensure that any exposure of patients to radiation is justified and the investigation appropriate. As a result, the clinician may expect the right answers in the report to his questions. This is applicable to non-ionizing radiological investigations as well.

A more recent cross sectional survey clearly demonstrated in almost a third of radiological requests, doctors have not seen patients to be investigated. This is most likely due to the shift working patterns [12]. Moreover the IRMER 2000 criteria are not satisfied potentially exposing patients to unnecessary and inappropriate radiation. Another study documented 24% of inappropriate requests in their study of Radiology Referral forms appropriateness using ‘The American College of Radiology (ACR) Appropriateness Criteria for Imaging and Treatment Decisions’ [13].

There are ways of improving the system of referral pattern to improve safety and reduce clinical errors. During induction the junior doctors should be oriented in order to know the importance of accurate patient information and the adverse effects of unnecessary radiation exposure [14-17]. Inclusion of certain mandatory fields in the request forms (e.g. creatinine, referring doctor, etc.), will necessitate the requesting physician to fill the details without fail.

Conclusions

Output from the radiologist will be in tune with the input from the referring clinician. Compliance with filling of the request forms is low as shown from the analysis in this audit. There is a need to redesign the request forms to provide more space for important fields to include clinical details, physician’s name, previous investigations etc. The radiology request forms should be reviewed by radiologists regularly to optimize the investigations and avoid unwarranted radiation. Comprehensive imaging request guidelines should be circulated to all the physicians.

Acknowledgement

The author is thankful to the MD & CEO for permitting to publish this communication. Thanks are also due to Ms. Rekha for the secretarial assistance.

Conflicts of interest

Author declares no conflicts of interest.