G Pitman Alexander
Rural Clinical School, The University of Melbourne, Parkville, Victoria, Australia.
J Med Imaging Radiat Oncol. 2017 Jun;61(3):299-303. doi: 10.1111/1754-9485.12577. Epub 2017 Jan 31.
Referral to a clinical radiologist is the prime means of communication between the referrer and the radiologist. Current Australian and New Zealand government regulations do not prescribe what clinical information should be included in a referral. This work presents a qualitative compilation of clinical radiologist opinion, relevant professional recommendations, governmental regulatory positions and prior work on diagnostic error to synthesise recommendations on what clinical information should be included in a referral. Recommended requirements on what clinical information should be included in a referral to a clinical radiologist are as follows: an unambiguous referral; identity of the patient; identity of the referrer; and sufficient clinical detail to justify performance of the diagnostic imaging examination and to confirm appropriate choice of the examination and modality. Recommended guideline on the content of clinical detail clarifies when the information provided in a referral meets these requirements. High-quality information provided in a referral allows the clinical radiologist to ensure that exposure of patients to medical radiation is justified. It also minimises the incidence of perceptual and interpretational diagnostic error. Recommended requirements and guideline on the clinical detail to be provided in a referral to a clinical radiologist have been formulated for professional debate and adoption.
将患者转介给临床放射科医生是转诊医生与放射科医生之间的主要沟通方式。澳大利亚和新西兰现行的政府法规并未规定转诊中应包含哪些临床信息。这项工作对临床放射科医生的意见、相关专业建议、政府监管立场以及先前关于诊断错误的研究进行了定性汇编，以综合得出关于转诊中应包含哪些临床信息的建议。关于转介给临床放射科医生的转诊中应包含哪些临床信息的推荐要求如下：明确的转诊；患者身份；转诊医生身份；以及足够的临床细节，以证明进行诊断性影像学检查的合理性，并确认检查和方式的适当选择。关于临床细节内容的推荐指南明确了转诊中提供的信息何时符合这些要求。转诊中提供的高质量信息可使临床放射科医生确保患者接受医疗辐射是合理的。它还能将感知和解释性诊断错误的发生率降至最低。已制定了关于转介给临床放射科医生的转诊中应提供的临床细节的推荐要求和指南，以供专业讨论和采用。
