Inadequately filled X-ray referral forms are still a major problem faced by radiology units in the world. Although there are no standard referral forms, each country has developed its own referral forms, including all the necessary details. The Ministry of Health, Nutrition and Indigenous Medicine in Sri Lanka has issued such forms to all the government hospitals in the country, where the referrals should be filled by the referring medical officer.
Usually, X-ray request form is the only means by which the radiologists gather clinical information about the patient when reporting an X-ray. Thus, properly filled request form with all the relevant clinical details is vital to provide a comprehensive report.
According to the audit findings, all the request forms contained the referral date, the name of the patient and the BHT number. Similar results were obtained for biodata information in an audit conducted in Nigeria . In this study, only 97% provided the date in the request form. In our study, five request forms did not provide information regarding the age and the sex of the patient. Given the fact that certain disease conditions, such as osteoporosis, myeloma, are prevalent among different age groups and sex, it is important to state details with regard to age and sex of the patient.
The major deficiency in relation to the completeness was observed in providing clinical data. Only 64 (37.2%) request forms contained detailed clinical history including the duration of symptoms and presence of red flag symptoms. In a study conducted in Nigeria showed a similar trend with 34.4% providing adequate clinical history . On the contrary, a study conducted in a separate state in Nigeria and Malta with regard to X-ray referrals, revealed 86.9% and 93.0% providing clinical details respectively [9,11].
Furthermore, there were indications that were not related to the lumbar spine and this is one of the serious defects, which should be addressed promptly. Being an investigation, which involves high radiation exposure, there should always be justification for requesting the investigation.
Use of non-standard abbreviation as the clinical indication is another main defect identified. While using standard abbreviations are justifiable, as these can be read and understood by the medical professionals, the use of non-standard abbreviations always leaves the reporting radiologist in dilemma in understanding the clinical scenario.
Although there are no standard guidelines recommending not to request for more than one region of examination in one request form, when requesting multiple regions of examination, it is important to provide necessary details for each region separately. In this audit, 34 request forms had more than one region of examination to be imaged. However, only 13 gave the relevant clinical details to each region.
In addition, it is important to note that illegible request forms lead to unnecessary time wastage and misleading information, both of which will negatively affect the quality of radiological reporting. Furthermore, illegible request forms may lead to obtaining inappropriate radiographs exposing the patients to unnecessary radiation.