Davies S, George A, Macallister A, Barton H, Youssef A, Boyle L, Sequeiros I
Department of Radiology, University Hospital Bristol NHS Foundation Trust, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, UK.
Department of Radiology, University Hospital Bristol NHS Foundation Trust, Bristol Royal Infirmary, Upper Maudlin Street, Bristol, UK.
Radiography (Lond). 2018 Aug;24(3):252-256. doi: 10.1016/j.radi.2018.03.005. Epub 2018 Apr 10.
The aim of this service evaluation project was to assess the quality of clinical details provided in radiological requests.
A retrospective review of adult inpatient and emergency department radiological requests over a seven-day period was performed, using the local Clinical Radiological Information System (CRIS). Requests for plain film, CT, MRI and Ultrasound were assessed for the inclusion of a clinical question, lateralisation/localisation of signs or symptoms if required, and relevant past medical/surgical history if available.
1548 imaging requests were analysed. 76% asked a specific clinical question. 74% of requests requiring localisation provided this. Of those cases with relevant past medical or surgical history available, 49% mentioned this. Emergency department (ED) requests provided localisation when required in 81% of cases compared to 62% of in-patients (p < 0.05). However, in-patient requests contained relevant past history in 53% of cases compared to 40% for ED requests (p = 0.00096). Compared to plain film requests, those for CT, MRI and Ultrasound studies were more complete in respect to inclusion of a clinical question (88% versus 72%, p < 0.05), localisation if required (83% versus 71%, p = 0.0007) and pertinent clinical history (67% versus 42%, p < 0.05). Requests from the weekend more often included a clinical question (83% vs 75%, p = 0.00054) and localisation if needed (84% vs 71%, p = 0.00188) compared with weekday requests.
This large-scale service evaluation project shows that the quality of clinical details in requests for radiological investigations requires improvement, particularly in regard to inclusion of relevant past medical and surgical history.
本服务评估项目的目的是评估放射检查申请中提供的临床细节质量。
使用当地临床放射信息系统（CRIS），对七天内成人住院患者和急诊科的放射检查申请进行回顾性审查。对X光平片、CT、MRI和超声检查申请进行评估，看是否包含临床问题、如有需要是否有体征或症状的定位信息，以及是否有相关既往病史（如有的话）。
分析了1548份影像检查申请。76%的申请提出了具体的临床问题。74%需要定位的申请提供了定位信息。在有相关既往病史的病例中，49%提到了这一点。急诊科申请在81%的情况下根据需要提供了定位信息，而住院患者为62%（p < 0.05）。然而，住院患者申请中有53%包含相关既往病史，而急诊科申请为40%（p = 0.00096）。与X光平片申请相比，CT、MRI和超声检查申请在包含临床问题（88%对72%，p < 0.05）、如有需要的定位（83%对71%，p = 0.0007）和相关临床病史（67%对42%，p < 0.05）方面更完整。与工作日申请相比，周末的申请更常包含临床问题（83%对75%，p = 0.00054）以及如有需要的定位（84%对71%，p = 0.00188）。
这项大规模服务评估项目表明，放射检查申请中的临床细节质量需要改进，特别是在包含相关既往病史方面。
