Clinical audit of computed tomography requisition form in a himalayan country, Nepal

Abstract

Introduction: Medical imaging requisition form is a vital document in the radiology department. Adequate filling ensures justification and effective communication which impacts patient care. This study aims to audit computed tomography (CT) requisition forms to determine their adequate filling and legibility in the Himalayan country, Nepal. Methods: A total of 239 CT requisition forms were collected from the Department of Radiology and Imaging, Bir Hospital, Kathmandu, Nepal through random sampling from June to August 2020. The availability of information such as demographic characteristics, clinical history, clinical diagnosis, differential diagnosis, and proper name of CT procedures was audited. The legibility of the provided information was categorized with the help of a senior radiographer having 10 years of experience. Results: Clinical history was present in 28 percent and clinical diagnosis in 64 percent of forms. Furthermore, 44 percent of contrast-enhanced procedures requiring IV contrast agents did not have a report of renal function test. Surprisingly, details on the last menstrual period for women of the reproductive age group were missing in all requisition forms. Conclusion: Available information is not sufficient for justification of patient dose. Clinicians need to fill up the requisition form properly for quality patient care in the radiology department.

Keywords

• Computed Tomography
• Requisition Form
• Audit
• Justification