Abstract
IntroductionRequest forms are important means of communication between physicians and diagnostic service providers. Pre-analytical errors account for over two thirds of errors encountered in diagnostic service provision. The importance of adequate completion of request forms is usually underestimated by physicians which may result in medical errors or delay in instituting appropriate treatment. The aim of this study was to audit the level of completion of request forms presented at a multidisciplinary diagnostic center.MethodsA review of all requests forms for investigations which included radiologic, laboratory and cardiac investigations received between July and December 2011 was performed to assess their level of completeness. The data was entered into a spreadsheet and analyzed.ResultsOnly 1.3% of the 7,841 request forms reviewed were fully completed. Patient's names, the referring physician's name and gender were the most completed information on the forms evaluated with 99.0%, 99.0% and 90.3% completion respectively. Patient's age was provided in 68.0%, request date in 88.2%, and clinical notes/ diagnosis in 65.9% of the requests. Patient's full address was provided in only 5.6% of requests evaluated.ConclusionThis study shows that investigation request forms are inadequately filled by physicians in our environment. Continuous medical education of physicians on the need for adequate completion of request forms is needed.
Highlights
Request forms are important means of communication between physicians and diagnostic service providers
Majority (68.2%) of laboratory errors occur in the pre-analytical phase which refers to procedures performed before the sample or patient gets to the diagnostic service provider and are not under the control of the laboratory personnel e.g. completion of a laboratory request form, specimen collection and identification, phlebotomy, sample handling and transportation to the laboratory [5,6]
Request forms for investigations received at a comprehensive diagnostic center between July and December 2011 were retrospectively evaluated to measure the compliance of referring clinicians in adequate completion of request forms
Summary
Request forms are important means of communication between physicians and diagnostic service providers. Request forms provide patient's details and information regarding the test to be performed and the importance of proper completion of these forms is usually emphasized early in physician training. Majority (68.2%) of laboratory errors occur in the pre-analytical phase which refers to procedures performed before the sample or patient gets to the diagnostic service provider and are not under the control of the laboratory personnel e.g. completion of a laboratory request form, specimen collection and identification, phlebotomy, sample handling and transportation to the laboratory [5,6]. Post-analytical error avoidance refers to the ultimate check on the pre-and intraanalytical quality This includes the reviewing pathologist or radiologist providing interpretative comments and the clinician's interpretation and reaction to the results [5,6]. The aim of this study is to assess the level of request form completion by physicians when requesting for investigations for their patients with a view to identify which information is most frequently overlooked
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