Assessment of Lab request forms: How do our clinicians communicate with Laboratory?

Abstract

Central clinical laboratory is an important division in the health care setup. Laboratory results help clinical decisions, follow up care and ensure patient safety. Laboratory request Form [LRF] is an important medium between the patient, a treating clinician and Laboratory. A meticulously filled LRF is important for patient care. Providing accurate and complete information in LRF is the doctor's responsibility. Erroneous LRF will have an impact on the quality of laboratory results. Present study evaluates the degree of completeness and correctness of quality indicators on laboratory request forms [LRF] to examine preanalytical standards of laboratory services.This study is a single center, prospective, cross sectional, descriptive type conducted at a 650 bed teaching hospital from Gujarat. In the span of a six months study period, 3735 [20% of total] LRFs were selected by simple random sampling method from the total LRF received at OPD blood collection center. They were analyzed for patient, clinician and sample identifier quality indicators along with completeness and correctness. Qualitative information was converted to quantitative by using two point scale, 0 score for incomplete information and 1 score for complete information.Among patient identifier quality indicators name, age, gender and location were filled in more than 75% forms whereas, very poorly filled 2% provisional diagnosis and 42% MRD number. Clinician identifier quality indicator was attended to in less than 50% forms. Time and date of request were absent on 100% forms. Sample identifier quality indicator shows 97% forms with the nature of the sample and 92% having investigation requests. Test requests on one third forms were invalid and inappropriate. 38% forms were incomplete and inappropriate whereas 46% forms had error in filling one or other data indicators.Appropriately filled LRF communicates well with the Central clinical laboratory. It will help in providing quality reports in time and benefit clinicians to manage quality care for patients. Hand written, poorly legible, inappropriately abbreviated, erroneous LRF are misleading and may compromise laboratory service and patient safety. Training and change in attitude towards LRF writing is required to maintain the standard of the health care system.