Clinical audit of the completion of CT scan request forms

对CT扫描申请单填写情况的临床审核

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Abstract

OBJECTIVE: To pilot study an audit looking at whether CT scan request forms are completed to an appropriate level. This was based on the adequacy of the detail provided and the use of abbreviations based on local trust guidance. METHODS: : 60 CT scan requests were retrospectively analysed at University Hospital South Manchester. The following factors were considered: clinical information provided, the offering of a differential diagnosis and use of abbreviations in requests. RESULTS: : Of the scan requests analysed, 44 (73%) were adequately completed according to the criteria set. The adequacy of requests and use of appropriate abbreviations varied between the types of scan being requested. There were 59 different abbreviations used in 34 of the requests (57%). Of these, only two (3%) were considered inappropriate.  CONCLUSION: : There is still room for improvement in the completion of CT scan requests at University Hospital South Manchester. The poor completion of the forms and use of poor abbreviations can have a detrimental effect on the reporting and therefore, care of the patient. It is important that this problem is tackled appropriately. ADVANCES IN KNOWLEDGE: : There is scope for improvement in the completion of CT request forms. This audit highlights this issue and provides the basis for implementing larger studies looking at completion of radiological request forms.

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