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.