Audit of Radiology Request Form for Completion and Usefulness of Clinical History: Teaching Hospital Experience, Ghana

Abstract

BACKGROUND: . We conducted a prospective review of 500 radiology request forms at the Cape Coast Teaching Hospital (CCTH) between September and October 2018. The forms were consecutively sampled and reviewed for each field/area such as patient's name, age, and clinical history. Data were analyzed descriptively for the level of completeness and usefulness of clinical history entered by the clinician. RESULTS: No request form was completed in full. All the request forms did not have X-ray serial number and previous examination details documented. The proportions of forms with various fields completed were as follows: more than 90% of the forms had patient's name, investigation required, date of the request, doctor's name, and clinical history fields filled. The patient's age, patient's ward/address, and doctor's address were filled in 88%, 75%, and 18.4%, respectively. Twenty percent of the request forms were not useful to the radiologist in the final diagnosis. CONCLUSION: A significant proportion of radiology request forms are incompletely filled and therefore denies the radiologist, the critical information needed to make a diagnosis, or narrow differential diagnosis.

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