Sardar Q, Qureshi M A, Nadeem A, Qureshi S, Rahim N, Bashir T, Mahmood T, Malik S, Ahmad W, Khan N, Dodhy K, Javid K, Zaidi N, Hassan S J.
An audit of quality of CT Scan reports in Radiology Department, Jinnah Hospital Lahore.
Pak Postgrad Med J Jan ;18(2):39-43.
Background: With a recent introduction of state of the art imaging modality like computerized tomography in tertiary care hospitals, a step in the direction of efficient and consistent reporting system is mandatory. The radiology report is required to provide the referring physician relevant information in an easy to understand format. Objectives: Objectives of this study were to examine the preferences of radiologist and referring physician, regarding content and style of reporting and to find any deficiency in reporting system. Material and methods: Study Setting: A retrospective survey was carried out to trace all the Computerized Axial Tomography Scan Reports carried out by the department of Radiology during six months time from January. 2007 to June 2007. Study Design: Retrospective cross sectional study. Data Collection: Data for analysis was collected from the main data present in the computer of CT scan section of the department. Data analysis: A Checklist of thirteen items necessary for Computerized Axial Tomography (CAT) Sea Reports was generated to evaluate the quality of reports. Each category has three responses to be ticked YES, NO and NA (not applicable) to indicate that it had been considered. Results: 2134 reports of CT scan done since January, 2007 to June 2007 were analyzed for quality of reports. The reports audit was divided into three categories. Demographic profile of patients, information to be provided by consulting or referring physician and information or impression by consultant radiologist. The audits revealed that 1.5% of the reports don`t have a patient name written on reports. 3.3% of the reports don`t have age mentioned. 38.8% of the reports don`t have gender mentioned. 78.7% does not have any referring physician name. 0.2% did not indicate region on which the CT scan was performed. 8.9% did not have protocol of CT mentioned 0.3% of the reports did have a radiologist opinion. 9.4% and 8.4% respectively did not have the incharge or accompanying consultant radiologist signature. 100% of the reports did not have the referring physician name. 100% of the reports did not have a reason for request by referring physician, 78.8% did not ha% e a clinical data of the patients or reasons for referral. 100% of reports have appropriate use of relevant abbreviations and no irrelevant abbreviations found. Conclusion: Overall quality of the reports is satisfactory. There is a need to organize necessary demographic information. There is deficit of referring physician information regarding disease and reason for imaging. Radiologist reports are satisfactory regarding clinical impressions and CT scan protocols and appropriate abbreviations used. The reporting formats need to be standardized with clear demographic and clinical data.
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