Laboratory Request Forms- How Well do Doctors Fill Them? A Look at the Practice at the Niger Delta University Teaching Hospital, Okolobiri, Bayelsa State, Nigeria

Abstract

Background: Laboratory investigations are often required to manage patients in the hospital. Laboratory request forms serve as a medium between the pathologists and the clinician. Improperly filled laboratory forms may result in misdiagnosis and inadvertent mix-up of patients results. We therefore undertook to document the extent to which Doctors properly fill laboratory request forms at the Niger Delta University Teaching Hospital, Okolobiri.

Methods: One thousand two hundred laboratory request forms which had already been filled out by various Doctors in the hospital between January and June, 2013 were randomly selected and analysed. The forms were evaluated to assess the completeness of information entered by the requesting Clinician.

Results: The patients' names and investigations requested were entered on all forms. 3.0% of forms did not state the gender of the patient, while 11.5% did not even give the age of the patient. 9.6% did not specify the patient's location and 34.0% did not have the patient's hospital number. 25.5% of forms also did not have the name of the attending Consultant and 15.5% did not have the name of the requesting Doctor, while 27.1% of all forms were not signed by the requesting Doctor. A working diagnosis was not stated on 16.5% of forms. Also, the date of collection and nature of the specimen were not stated on 21.5% and 11.0% of forms respectively.

Conclusion: Laboratory request forms are not always properly filled by Clinicians. Only the patients' names and the requested investigations were filled on all forms. There is the need to remind Clinicians of the importance of carefully filling laboratory request forms.

Keywords: Laboratory request; form completion; Doctors documentation; Nigeria