Adequate Completion of Radiology Request Forms [QSI Ref: XR-501]
Descriptor
Adequacy of completion of radiology request forms.
Background
The usefulness of a radiological examination can be reduced if the clinical background and the specific problem to be answered is not provided with the request.
Inadequate information can also lead to mistakes in patient identification and delay in returning reports to the correct destination, and can reduce the value of the report.
Providing adequate clinical information is an essential component of IR(ME)R 2000.
The Cycle
The standard:
All radiology request forms should contain adequate clinical and demographic information which identifies the patient and the destination for the report.
All referrals should include the following:
• the clinical background
• the question to be answered
• the patient’s name, age, address and number
• the ward or location of the patient
• the name of the requesting practitioner and the name of the consultant or GP looking after the patient
Target:
100%
Assess local practice
Indicators:
Percentage of request referrals with adequate information.
Data items to be collected:
For each request referral, record the presence or otherwise of each of the items in the standard.
Suggested number:
200 consecutive referrals.
Suggestions for change if target not met
- Hold meetings with individual clinical firms to discuss the findings of this audit, and the requirements of the Department of Clinical Radiology
- Include the basic principles at induction of new staff
- In specific cases:
• Send back individual referals which are incomplete
• Check the patient’s notes to confirm the reason for the request
- Consider including mandatory fields - much easier to do now in most systems where the referral process is electronic, rather than paper.
Resources
Prospective data collection as requests are received is advised, as otherwise vetting process should have removed all inappropriately completed requests
4–6 hours
References
-
Royal College of Radiologists. iRefer: RCR referral Guideines 8th Edition London: RCR, 2017 https://www.irefer.org.uk/guidelines/about-guidelines/communication-radiology-service
Editor’s comments
The introduction of electronic requesting may obviate the need for some of these parameters to be collected if fields are mandatory but checks may still need to be made that details provided are accurate, eg patient location. Another issue which electronic ordering may result in, out of date clinical information being reused. This too should be audited. This audit can be used to provide quantitative data in areas which have been identified anecdotally as a problem, eg certain departments or certain procedures. Getting one of the relevant department staff to do this audit in conjunction with radiology can give them more ownership of data and willingness to tackle problems revealed.
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Taken from Clinical Audit in Radiology 100+ recipes RCR 1996, updated by CRAC