Study of Missing Clinical Details in Computed Tomography Radiology Request Forms: A Descriptive Cross-sectional Study

ABSTRACT Introduction: Detailed clinical history through a properly filled requisition form can help a radiologist in making a diagnosis. The objective of this study was to observe the missing clinical details of Computed Tomography requisition forms at radiology department in tertiary care hospital. Methods: This descriptive cross-sectional study was done in 196 Computed Tomography requisition forms in the department of radiology from September 2019 to October 2019. Ethical clearance from the Institutional Review Committee - Reference No. 120720194 was obtained. An informed consent from the participants was taken prior to the procedure. Convenient sampling was done. The data obtained were computed and analyzed using Statistical Package for Social Sciences to tabulate the results. The results were displayed in frequency and proportion of binary data. Results: All the request forms had name filled, however date was filled in 183 (93.4%), age was filled in 195 (99.5%), sex was filled in 193 (98.5%) and address was only in 30 (15.3%) of the forms. Clinical history and provisional diagnosis were written in 179 (91.3%) forms. Signature was found in more than half of forms 135 (68.9%) whereas the department referring the patient was filled in 92 (46.9%) of forms and the name of doctor referring the patient was not filled mostly. The handwriting was clear in 191 (97.4%) of cases and standard words were used. Use of non-standard abbreviation was found in only 2 (1%) forms. Conclusions: Clinical details were filled in most of the requisition forms however other parameters were still incompletely and inadequately filled.


INTRODUCTION
Radiologists report informally that missing clinical information is a daily occurrence and is a constant source of irritation and delay in giving computed tomography (CT) reports. 1 A radiologist helps in making a diagnosis. This can only be achieved if the clinicians give a detailed clinical history through a properly filled request form. These are documented requests filled by clinicians with demographic details, clinical history, provisional diagnosis and referring physician's signature. 2 Complete filling of the forms is important for radiologists to give concise diagnosis and avoid unhelpful examinations and radiation exposure. 3 Inadequate information can reduce the value of the report and leading to a mistake in patient identification and delay in returning reports to correct destination. 4 The objective of this study was to find out the prevalence of adequate filling of request forms of CT scans in radiology department of Kathmandu Medical College and Teaching Hospital.

METHODS
This descriptive cross-sectional study was carried out on CT requisition forms from September 2019 to October 2019 in the department of radiology of Kathmandu Medical College and Teaching Hospital. Ethical clearance from the Institutional Review Committee -Reference No. 120720194 was obtained. Informed consent of the participants was taken prior to the procedure. All the details in the requisition forms were recorded. All the CT scan forms were included for study. Patients who did not give consent were not included in this study. Convenient sampling was done and the sample size was calculated with prevalence 50%.
The sample size (n) was calculated as follows: Where, n= Sample size Z= 1.96 for 95% confidence interval p = prevalence (50%) q = 1-p e= margin of error, 7 % Hence, the total sample size taken was 196.
The data obtained were computed and analyzed using SPSS to tabulate the results. The results were displayed in frequency and proportion of binary data.

RESULTS
A total of 196 CT request forms were studied for their completion. All the request forms had name filled, however date was filled in 183 (93.4%), age was filled in 195 (99.5%), sex was filled in 193 (98.5%) and address was only in 30 (15.3%) of the forms (Table 1). Clinical history and provisional diagnosis were written in 179 (91.3%) forms and it was missing in 17 (8.67%) requisition forms (Figure 1).

Clinical History and Provisional Diagnosis Written Missing
Signature was found in more than half of forms 135 (68.9%) whereas the department referring the patient was filled in 92 (46.9%) of forms and the name of doctor referring the patient was not filled mostly ( Table  2).

3.
Signature 135 (68.9) The handwriting was clear in 191 (97.4%) of cases and standard words were used. Use of non-standard abbreviation was found in only 2 (1%) forms (Table 3).

DISCUSSION
The radiology requisition forms are usually the only means of communication between clinician and radiologists. 5 The opportunity to discuss cases between clinician and radiologist is not always possible. Whenever necessary, additional information can be acquired by radiologist by contacting patient or referring physician. 6 Incomplete filling of radiology request forms is a worldwide problem. 7 The Royal College of Radiologists clearly suggested that all radiology request forms should be adequately and legibly completed to avoid any misunderstanding of the request. 8 The level of information in radiology request forms reflect the quality of radiology reports. 9 Inadequate information in demographic details may affect in identification of the Illegible handwriting and use of non-standard abbreviations were found in 2.6% and 1% of cases. This finding is least common compared to previous studies by Akintomide et al, Rao and Jumah et al. 11,13,14 The observation of missing clinical details in CT requisitions had different results in different studies. Some found it be less while other found it be high. Most of the requisition forms in my study had clinical details written on it with legible handwriting and very less use of non-standard abbreviations.
The sample size was small in this study which might make the results less generalizable. Information like last menstrual period, renal function tests, allergic history and current usage of drugs like metformin are very important factors for consideration for CT scan which were missing in the requisition form of our hospital.

CONCLUSIONS
Clinical details were filled in most of the requisition forms however other parameters were still incompletely and inadequately filled.