评估实验室测试申请表的完整性

Chioma T. Udeh, O. Olayanju, N. Awah, O. Bamidele, Bola J Eseile, Onyinye Okwonkwo, G. Odok
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摘要

背景:实验室检查申请表通常随患者样本一起送到实验室,提供患者的生物数据和临床细节。这些信息是为了识别和指导病理学家准确解释患者的结果。然而,临床医生通常不提供所有必需的信息,因此使得解释困难。这种不完整的频率在本研究中被评估。方法:对2020年7月至9月在化学病理实验室收到的实验室申请单进行评估,以确定所有所需参数的完整性。本研究分析的参数包括年龄、性别、医院编号、地点、临床信息、请求医生姓名和请求日期。缺失参数的频率表示为总遗漏的比例(%)。结果:本研究共收到调查表1906份,其中789份(41.4%)至少缺少一个参数。除患者姓名、样本性质和调查要求外,其他参数均被遗漏,共遗漏1117项。年龄(287;25.7%)医院编号(264;23.6%)和临床资料(246;22%)是最常被忽略的参数。大多数遗漏(69%)来自门诊诊所,20%来自病房,10%的表格没有指明病房或诊所。结论:临床医师填写化验申请单不完整是常见病。必须不断努力使他们认识到每一个必要参数的重要性,以确保明显的改进。
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Assessment of laboratory test request forms for completeness
Background: Laboratory test request forms usually accompany patient’s samples to the laboratory, providing biodata and clinical details of the patient. This information is for purposes of identification and guiding pathologists to accurately interpret patient’s result. Clinicians however do not usually provide all the required information, thus making interpretation difficult. The frequency of such incompleteness is assessed in this study.Methods: Laboratory request forms received at the Chemical Pathology laboratory between July and September 2020 were assessed for completeness of all the required parameters. Parameters analyzed in this study included age, gender, hospital number, location, clinical information, name of requesting physician and the date of request. Frequency of missing parameters were expressed as proportions (%) of the total omissions.Results: There were 1906 request forms received during the course of this study and 789 (41.4%) of them had at least one missing parameter. Apart from patients’ names, nature of sample and the requested investigation, all other parameters were omitted at one time or the other making a total of 1117 omissions. Age (287; 25.7%) hospital number (264; 23.6%) and clinical information (246; 22%) were the most commonly omitted parameters. Majority of the omissions (69%) were from the outpatient clinics, 20% were from the wards while 10% of the forms had no ward or clinic indicated.Conclusion: Incomplete filling of laboratory test request forms is a regular occurrence among clinicians. Effort must be made to continually sensitize them of the importance of each of the required parameters to ensure a visible improvement.
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