APRIL 4, 2014

HARARE SCHOOL OF RADIOGRAPHY

ABSTRACT
Background: The radiology request form is an essential communication tool that facilitates patient referral for
radiological investigations. Complete and accurate request forms are prerequisite to justifying medical exposure to
ionizing radiation. The chest x-ray is the most commonly requested radiological examination in paediatrics.
However, paediatric diagnostic radiological examinations carry higher risk per unit of radiation dose for the
development of cancer in infants and children when compared to adults. The researcher was motivated by a need
to ensure efficiency in the use of the x-ray request form at Harare Childrens Hospital; in order to optimize radiation
protection, minimize clinical information miscommunication and improve service efficiency.
Objectives: The study aimed to objectively measure the adequacy and accuracy of request form information in
justification of paediatric chest x-ray examinations, measured against standard referral-form guidelines; as well as
assessing the relevance of the details required vis--vis information provided by referring clinicians on the form, in
order to identify causes of problem areas and the possible effects in paediatric radiation protection.
Setting: The study was conducted at the Harare Central Hospital and Harare Childrens Hospital complex.
Methods: Observations of chest x-ray requests done using the current x-ray request form template that is in use at
Harare Central Hospital was done. Using a standardized scoring system, a representative sample of randomly
selected request forms received at Harare Central Hospital X-ray department from Harare Childrens Hospital over
a period of six weeks was used. A checklist of the collected forms was created indicating the various fields and
level of information completion. Open and closed response questionnaires were also used for doctors and
radiographers and outcomes were used to support the record-observation method.
Results and Conclusions: The outcome revealed that the average completion level per request form was only
38.3%. Referrers and radiographers cited a number of factors and reasons for the inconsistencies observed.
Another key sub-optimal trend was observed in the completion of patients clinical details which affects the
justification of the examinations, in view of radiation protection. When measured against international standards and
guidelines, request form information being provided at the hospital is insufficient and inaccurate to justify medical
radiation exposure. The trends observed have negative effects on radiation protection and dose optimisation and it
affects patient care, the efficiency of the x-ray department and the integrity of the referral system. The researcher
came up with key recommendations that that include the implementation of a laid-down referral protocol and
refresher courses on radiation protection; and a further holistic research on paediatric referrals was suggested.
Keywords: Request forms, Justification, Accuracy, Adequacy, Ionizing Radiation, Radiation protection, Paediatric
radiography, Chest X-ray, Communication,
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ACKNOWLEDGEMENTS
I would like to thank my beloved family, for being the crown of Gods loving-kindness in my life and giving
me the reason to continue working.
I would also like to acknowledge my research supervisor, fellow students and tutors for their assistance
with resources, knowledge, guidance and moral support during the course of the research. I am grateful to
the clinicians and radiographers who took time from their busy schedules to participate in the research; as
well as the authorities at Harare Central Hospital who allowed me the opportunity to carry out the study.

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DEDICATION
Unto him who is able to keep me from falling and to present me without fault and with great joy to the
only wise God our Saviour, be glory, majesty, power, authority, strength, honour, praise and thanksgiving
though Jesus Christ our Lord, before all ages, now and forever more! Amen.

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TABLE OF CONTENTS
CONTENTS:

PAGE

ABSTRACT:

Acknowledgements

ii

Dedication

iii

Glossary

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CHAPTER 1: Introduction
1.1.1

The X-Ray Request Form

1.1.2

Ionizing Radiation: Paediatric s Chest X-Rays

1.2

Background

1.3

Statement of the Problem

1.4

AIMS OF THE STUDY

1.5

Research Questions

1.6

OBJECTIVES

1.7

Justification

CHAPTER 2: LITERATURE REVIEW

2.1

Introduction

2.2

The X-Ray Request Forms

2.3

Contents of the Request Forms

2.4

Paediatric Radiology: Chest X-Rays

2.5

Risk Assessment of Medical Radiation Exposure

2.6

Justification and Overutilization

2.7

Communication and Clinical Errors

2.8

Medico-Legal Issues

2.9

Service Quality and Turnaround Time

2.10

Dose Reduction Policies and Awareness

2.11

Responsibilities of Referring Clinicians

2.12

Responsibilities of Radiologists

2.13

Responsibilities of Radiographers

10

2.14

Current Research Findings and Contributions.

10

CHAPTER 3: METHODS
3.1

Introduction

12

3.2

Research Setting

12

3.3

Study Design

12

3.4

Population and Sample Size

12

3.5.1

Research Instruments: Observation Method

13

3.5.2

Research Instruments: Closed-Response Questionnaires

13

3.6

Inclusion and Exclusion Criteria

13

3.7

Validity and Reliability

14

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3.8

Pre-Testing of Research Tools

14

3.9

Outcome of the Trial

14

3.10

Data Presentation and Analysis

15

3.11

Ethical Considerations

15

CHAPTER 4: DATA PRESENTATION

4.0

Introduction

16

4.1

Demographic Data

16

4.2

Adequacy of information: The Request Form Observation Score Sheets

18

4.3

Radiographers Evaluation of Request Form Completion

20

4.4

Radiographers Expectations and Perceptions on Required Information

20

4.5

Doctors Compliance and Perceptions on Required Information

21

4.6

Who Is Referring Patients?

23

4.7

Referral Protocols and Guidelines

23

4.8

Justification of Medical Radiation Exposure

24

4.9

Relevance and Accuracy of Information Provided

26

4.10

Radiographers Course of Action in Addressing Request Form Queries

27

4.11

Doctors opinions on causes of request-form discrepancies

27

4.12

Effects on Radiation Protection

28

4.13

Effects on Patient Care

28

4.14

Effects on Workflow

28

4.15

Recommendations

28

4.16

Summary

28

CHAPTER 5: DISCUSSION
5.0

Introduction

29

5.1

Levels of Completion of the Request Form

29

5.2

Relevance and Accuracy of Information Provided

30

5.3

Justification of Medical Radiation Exposure

30

5.4

Reasons and Grounds for Non-Compliance

31

5.4.1

Referral Protocols and Guidelines

31

5.4.2

Demographic Correlation

32

5.4.3

Radiographers and Referrers Perceptions on Required Information

32

5.5

Effects of Request Form Irregularities

33

5.6

Limitations of Research Instruments

34

5.7

Summary

34

CHAPTER 6: Recommendations
6.1

Conclusion

35

6.2

Recommendations

36

LIST OF REFERENCES

37

LIST OF FIGURES
Fig 4.1.1: Radiographers Gender Distribution

16

Fig. 4.1.2: Doctors Gender Distribution

16

Fig 4.1.3: Age Distribution of Referrers

17

Fig 4.1.4: Professional Experience of Referrers

17

Fig 4.1.5: Professional Experience of Radiographers

18

Fig 4.2.1: Request Form Scores

18

Fig 4.4.1: Is some required information unnecessary?

20

Fig 4.5.1: Is some required information unnecessary?

21

Fig 4.5.2: Reasons for inadequate clinical information

22

Fig 4.7.1: Doctors use of referral protocols

23

Fig 4.7.2: Radiographers use of standard protocols

23

Fig. 4.8.1: Are all your requests absolutely necessary?

24

Fig 4.8.2: Do you consider other alternative modalities?

25

Fig 4.8.3: Reasons for requesting chest x-rays

25

Fig 4.9.1: Queries Raised by Radiographers

26

Fig 4.10.1 Radiographers Query Resolution Flow Chart

27

LIST OF TABLES
Table 4.1.1:

Professional Level of Radiographers

17

TABLE 4.2.1

Request Form Scores (Per Form)

18

TABLE 4.2.2

Overall Request Form Completion Scores (Per Form-Field)

19

Table 4.3.1

Level of Completion of Form Field and Relative Frequency

20

Table 4.5.1

Importance of Request Form Information

21

Table 4.5.2

Do You Provide the Necessary Clinical Details?

22

Table 4.11.1

Important Factors Causing Request Form Problems

27

APPENDICES

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GLOSSARY
ALARA/ ALARP

As-Low-As-Reasonably-Achievable/ As-Low-As-Reasonably-Practicable (radiation dose).

ASRT

American Society of Radiologic Technologists (US)

ECRP

European Commission for Radiation Protection

IAEA

International Atomic Energy Agency

Ionizing Radiation

Electromagnetic wave energies capable of causing positive or negative charges when they
interact with body molecules.

ICRP

International Commission for Radiation Protection

MOHCW

Ministry of Health and Child Care (Zimbabwe)

NHS

National Health Services (UK)

Radiograph

An image obtained in X-Ray examinations.

Radiology

A branch of medicine concerned with the use of radiation energy or radioactive material in
the diagnosis and treatment of diseases.

RCR

Royal College of Radiologists (UK)

Request Form

A template form used in radiology referrals.

RPAZ

Radiation Protection Authority of Zimbabwe

WHO

World Health Organization

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