Clinical Information from the Emergency Department

Adequacy of clinical information on referrals from the Emergency Department(ED).

There is evidence that inadequate clinical information is associated with an increased level of inaccurate reports (Ref. 1–3). Accurate clinical information is more likely to assist the radiologist or reporting radiographer in constructing an accurate and relevant report that aid the referring practitioner with the management of the patient.

The standard: 

A locally agreed standard.

All requests for imaging should contain all the relevant clinical information.

Target: 

100%

Indicators: 

% of request forms or electronic requests containing adequate clinical information.

Data items to be collected: 

Assess request forms or electronic requests on a simple proforma completed at the time of reporting Emergency Department images.

For each request, record if the information provided was adequate :

• a relevant clinical history ;

• The primary clinical diagnosis queried
• Relevant differentials listed if applicable
• Blood results that are relevant to the clinical history   

• the clinical signs;

• (trauma only) the precise site of injury;

• identifier for the person making the request (name and grade).

Suggested number: 

200 consecutive requests.

1.  Hold meetings between the radiologists and the ED staff to discuss the areas in which improvement is required.

2.  Provide formal instruction on how to complete requests (forms or electronic requests).

3.  Design and provide a request proforma which is specifically designed for ED officers and nurse practitioners, with a view to obtaining excellent clinical information. Consider making some fields mandatory in the request proforma to ensure better compliance with the standards.

4.  Identify any referrer with a poor record of completing requests and discuss the benefits of good information.

1.  Prospective data recording.

2.  Data analysis assistance from the Audit Office: 3 hours.

3.  Radiologists: a total of 3 hours.

1. Rickett AB et al. The importance of clinical details when reporting accident and emergency radiographs. Injury 1992;23:458–60.7.8. Triantopoulou Ch, Tsalafoutas I, Analysis of radiological examination request forms in conjunction with justification of X-ray exposures. Eur J Radiol. 2005 Feb;53(2):306-11. www.ncbi.nlm.nih.gov

2. Berbaum KS et al. Impact of clinical history on fracture detection with radiography. Radiology 1988;168:507–511.

3. Berbaum KS et al. Influence of clinical history upon detection of nodules and other lesions. Invest Rad 1988; 23:48–55.

4. de Lacey GJ et al. An assessment of the clinical effects of reporting accident and emergency radiographs. Br J Radiol 1980;53:304–309.

5. Berbaum KS et al. Impact of Clinical History on radiographic detection of fractures: a comparison of radiologists and orthopedists. AJR 1989;153:1221–4.

6. Seltzer SE et al. Resident film interpretation. A staff review. AJR 1981;137:129–33.

7. Vincent CA et al. Accuracy of detection of radiographic abnormalities by junior doctors. Arch Emerg Med 1988;5:101–109

Dr G Kaplan and Dr D Remedios Updated by CRAC 2015, Updated by Dr H Bailey 2018