A study of adequacy of completion of radiology request forms

Oswal, Dilip; Sapherson, D.A.; Rehman, Amer

doi:10.1016/j.radi.2008.05.003

Cited by 21 publications

(16 citation statements)

References 4 publications

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“…The conclusions were that abbreviations that are not universally accepted were observed in all forms. The results of this study concurred with those of the previous study which indicated that forms were often inadequately completed [2]. Continued professional development for all referrers in order to give value to the complet ion of clin ical forms was reco mmended.…”

Section: Completeness Of Clinical Datasupporting

confidence: 88%

“…H 2 The observed referral in formation will be significantly less complete than the prescribed general standard.…”

Section: Figure 3 Conceptual Frameworkmentioning

confidence: 99%

“…Workers " Co mpensation Rehabilitation Centre (W CRC) is a public institution that is regulated under the Health Professions Council of Zimbab we, as such clinical audit provides an opportunity to the WCRC staff to fo llo w standard protocols, protects them fro m medico legal pit falls, establishes the basis for quality clinical practice and also ensures that rehabilitees were getting the quality of services in a standard manner across the board. However, in order to get quality o f services in a standard manner across the board, organisational data capture template forms that represent the framework for documenting patient data must have adequate form fields that are completely and accurately filled in as an integral part of note-keeping in clinical pract ice [2]. Such practice allows clin icians to provide informed and justified care across departments.…”

Section: Introductionmentioning

confidence: 99%

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An Audit of Documented Rehabilitees` Data at the Workers` Compensation Rehabilitation Centre (WCRC) in Bulawayo, Zimbabwe

Bongani¹

2013

AJPHR

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The primary objective of Workers" Compensation Rehabilitation Centre is to provide clinical rehabilitation services to patients who have work related injuries. To do this, the centre requires complete rehabilitees" data to be transmitted from the referrer to the centre as well as across internal departments for the centre. This is because documentation of medical records is a fundamental tool for communication between health professionals. It informs the care provided, treatment, care planned and the outcome of that care as a continuous and contemporaneous record. However, the researcher was not aware of any clinical audit of documented rehabilitees" data with respect to compliance with this requirement. This prompted a review of rehabilitees" data for its completeness as a vital initial step towards optimisation of rehabilitees" care pathways. The research method was a non-participatory document review of quota sampled discharged rehabilitees" files using a descriptive and analytical research design. Data were captured using a structured data collection instrument designed and tested by the experts in the medical fraternity. The instrument was designed from information prescribed in internationally referred documents and refined using information prescribed in the Procedures Manual for the centre. Generally, rehabilitees" information was incomplete thereby making the referral and review of patients difficult. Clinical template forms in use at the research site had inadequate form fields and this was an important factor which modelled the level of completeness of rehabilitees" information. These inadequate form fields resulted in important facts about the rehabilitees not efficiently transmitted across departments so much that there was practically no meaningful documented dialogue on balancing benefits with the risks to patients. There is need to revise the content of the procedure manual to prescribe that all clinicians file co mplete discharge reh abilitees" information in one folder as part of improving documentation in line with the principle of medical care and international standards.

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Section: Completeness Of Clinical Datasupporting

confidence: 88%

“…H 2 The observed referral in formation will be significantly less complete than the prescribed general standard.…”

Section: Figure 3 Conceptual Frameworkmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 1 more Smart Citation

An Audit of Documented Rehabilitees` Data at the Workers` Compensation Rehabilitation Centre (WCRC) in Bulawayo, Zimbabwe

Bongani¹

2013

AJPHR

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“…Other publications have shown substandard completion of RRFs. For example, Oswal et al 2 looked at 400 RRFs, and assigned a score out of 10 to each depending on how well 10 aspects of the form were completed. The average score was 8.7.…”

Section: Discussionmentioning

confidence: 99%

Requesting radiological investigations – do junior doctors know their patients? A cross-sectional survey

et al. 2013

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ObjectivesTo ascertain clinicians' knowledge of their patients when requesting radiological investigations, as required legally by UK government legislation ‘Ionising Radiation (Medical Exposure) Regulations 2000’ (IRMER 2000), following the implementation of European Working Time Directive.DesignCross sectional survey.ParticipantsAll doctors requesting radiological requests every Monday, following the weekend on-call, over an 8-week period. There were no exclusion criteria.Main outcome measuresBaseline data analysis, including grade and specialty of requesting doctor, types of modality requested, knowledge of their patient, addressograph signature confirming identity and appropriateness of investigation.Results164 requests were received, the majority (61%) were made by Foundation Programme 1 (FP1) doctors and general medical specialties accounted for the highest proportion of requests (45%). Ultrasound scanning was the most frequently requested investigation (47%), closely followed by computed tomography (CT) scans (42%). Almost a third (30%) of requests were made by doctors who had not seen the patient to be investigated, predominantly by FP1 doctors (p=0.003) and more frequently by general medical specialties (p=0.001). Signatures were absent on 20% of the addressographs and overall, 10% of requests were deemed inappropriate.ConclusionsIn almost a third of radiological requests, doctors have not seen patients to be investigated, most likely as a result of shift working patterns. This does not fulfil the IRMER 2000 criteria and potentially exposes patients to unnecessary and inappropriate radiation.

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“…There is growing evidence that medical imaging is prone to failures in communication, particularly the communication of critical and non-critical test results [13][14][15] and inadequate communication of patient information on the request form [16,17]. With increasing complexities of care, technological advances in imaging and electronic communication systems have seen new types of errors emerging [18].…”

mentioning

confidence: 99%

Learning from incident reports in the Australian medical imaging setting: handover and communication errors

Hannaford

Mandel²,

Crock³

et al. 2013

BJR

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Objective: To determine the type and nature of incidents occurring within medical imaging settings in Australia and identify strategies that could be engaged to reduce the risk of their re-occurrence.Methods: 71 search terms, related to clinical handover and communication, were applied to 3976 incidents in the Radiology Events Register. Detailed classification and thematic analysis of a subset of incidents that involved handover or communication (n5298) were undertaken to identify the most prevalent types of error and to make recommendations about patient safety initiatives in medical imaging.Results: Incidents occurred most frequently during patient preparation (34%), when requesting imaging (27%) and when communicating a diagnosis (23%). Frequent problems within each of these stages of the imaging cycle included: inadequate handover of patients (41%) or unsafe or inappropriate transfer of the patient to or from medical imaging (35%); incorrect information on the request form (52%); and delayed communication of a diagnosis (36%) or communication of a wrong diagnosis (36%). Conclusion:The handover of patients and clinical information to and from medical imaging is fraught with error, often compromising patient safety and resulting in communication of delayed or wrong diagnoses, unnecessary radiation exposure and a waste of limited resources. Corrective strategies to address safety concerns related to new information

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A study of adequacy of completion of radiology request forms

Cited by 21 publications

References 4 publications

An Audit of Documented Rehabilitees` Data at the Workers` Compensation Rehabilitation Centre (WCRC) in Bulawayo, Zimbabwe

An Audit of Documented Rehabilitees` Data at the Workers` Compensation Rehabilitation Centre (WCRC) in Bulawayo, Zimbabwe

Requesting radiological investigations – do junior doctors know their patients? A cross-sectional survey

Learning from incident reports in the Australian medical imaging setting: handover and communication errors

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