Adequacy of Completion of Computed Tomography Scan Request Forms at a Tertiary Care Center in Pakistan: A Clinical Audit

Introduction A lot of radiation exposure to a population comes from medical sources. Clinicians must justify the need for radiology procedures on a request form to prevent unnecessary scans and radiation exposure. Moreover, the properly-filled form will help to identify the patient correctly and provide clinical details to make a radiological diagnosis. Objective The purpose of the study was to audit the computed tomography (CT) scan request forms and find out the adequacy of completion of the request forms at Bahawal Victoria Hospital, Bahawalpur, Pakistan. Materials and methods We scrutinized 300 CT scan request forms received at the tertiary care center, Bahawal Victoria Hospital. We checked the adequacy of filling of different fields in the request forms like name, address, clinical and surgical history, and the name of required examination. We also looked for the missing subjects in the CT request form currently used in our hospital like the contact numbers of the patient and the doctor, the identity of the requesting doctor, renal function tests (RFTs), last menstrual period (LMP), and history of allergy. The results were analyzed using Statistical Package for the Social Sciences 20 (SPSS 20) (IBM, NY, USA) and Microsoft Office Excel Worksheet (Microsoft Corporation, NM, USA). Results The name of the patient was present in 100% of the request forms, surname in 27.66%, age in 73.33%, gender in 64.33%, date in 91.66%, bed number in 37.90%, address in 1% and the name of required examination in 99.6%. Information about diagnosis included clinical history in 50.66%, past surgical history in 1%, laboratory investigations in 1%, and clinical examination in 8.66% of the forms. All the forms had the name and signature of the referring consultant, but only 10.33% forms contained the identity of the requesting junior doctor. More than half of the request forms for CT scan provided RFTs. We found no record of the allergy, LMP, and the contact number of the doctor and the patient. Conclusion The information provided in the CT scan request forms was inadequate. The practice of filling these forms needs to be improved to protect the patients from unnecessary radiation exposure.