RESUMEN:
Introducción: Reconociendo la importancia de los exámenes de imagen en la práctica clínica y la impactante influencia de la información clínica proporcionada en la calidad del informe radiológico producido, nos propusimos estudiar las prácticas relacionadas con la completitud de los campos de llenado obligatorio en las solicitudes de exámenes de imagen por parte de los médicos de un hospital portugués. Materiales y métodos: Realizamos un análisis retrospectivo de 2930 exámenes de imagen solicitados durante el mes de mayo de 2022 por los médicos de nuestro hospital, incluyendo ecografías, tomografías computarizadas y resonancias magnéticas. Los datos fueron categorizados en función del llenado de la información proporcionada (completa/incompleta/ausente), lugar de origen de la solicitud (consulta externa; hospital de día; internamiento; urgencia), examen solicitado y región anatómica evaluada. La asociación entre variables fue evaluada utilizando el análisis chi-cuadrado de Pearson. Resultados: De las 2930 solicitudes de exámenes de imagen, el 71,4% fueron acompañadas de información clínica adecuadamente completada, el 27,3% de las solicitudes estaban incompletas y el 1,3% con información ausente. El examen más solicitado fue la tomografía computarizada, que correspondió al 68,1%. Se identificaron asociaciones significativas (p < 0,05) entre la adecuación del llenado de la información clínica y el método de imagen solicitado, así como entre el lugar de origen de la solicitud del examen y la completitud de la información clínica y qué información faltaba. La información clínica fue más frecuentemente completada de manera adecuada en las solicitudes originadas en la consulta externa (73,4%). Discusión: El hecho de que en nuestro hospital no todas las solicitudes estén acompañadas de información clínica adecuadamente completada muestra que hay espacio para optimizar las prácticas de llenado vigentes. También, la comprensión de los factores que impactan en su adecuado llenado nos permite desarrollar formas de actuación con el fin de optimizar los recursos disponibles. Algunas de las medidas implementadas incluyen programas de sensibilización y capacitación, así como la adopción de sistemas de información electrónicos que faciliten este proceso. Además, es crucial promover una comunicación abierta entre radiólogos y clínicos. Conclusión: Nuestros resultados subrayan la necesidad de mejorar la comunicación y la formación en el proceso de solicitud de exámenes de imagen para mejorar la calidad de la atención médica proporcionada en nuestro hospital.

ABSTRACT:
Introduction: Acknowledging the importance of imaging examinations in clinical practice and the impactful influence of provided clinical information on the quality of the produced radiological report, we aimed to study the practices related to the completeness of the mandatory fields in imaging requests by doctors working in a Portuguese hospital. Materials and methods: We retrospectively analysed 2930 imaging requests ordered during May 2022 by physicians at our hospital, including ultrasound, computed tomography and magnetic resonance. Data were categorized based on the completeness of the provided information (adequately filled out/incomplete/absent), the origin of the request (outpatient consultation; outpatient clinic; inpatient; emergency), requested examination, and evaluated anatomical region. The association between variables was assessed using Pearson’s Chi-square analysis. Results: Of the 2930 imaging examination requests, 71.4% were accompanied by adequately filled clinical information, 27.3% of the requests were incompletely filled, and 1.3% were lacking information. The most frequently requested examination was computed tomography comprising 68.1% of total requests. Significant associations (p < 0.05) were identified between the adequacy of clinical information completion and the requested imaging method, as well as between the origin of the examination request and the completeness of the clinical information and which information was missing. Clinical information was most frequently adequately filled in requests originating from outpatient consultation in 73.4%. Discussion: The fact that at our hospital not all requests are accompanied by adequately filled clinical information shows that there is room to optimize current practices. Understanding the factors impacting its adequate completion allows us to develop approaches aimed at optimizing available resources. Some of the implemented measures include awareness and training programs as well as the adoption of facilitating electronic information systems. Furthermore, fostering open communication between radiologists and clinicians is crucial. Conclusion: Our findings underscore the need for enhanced communication and training in the imaging request process to improve the quality of health care provided at our hospital.

ABSTRACT:
Introduction: Acknowledging the importance of imaging examinations in clinical practice and the impactful influence of provided clinical information on the quality of the produced radiological report, we aimed to study the practices related to the completeness of the mandatory fields in imaging requests by doctors working in a Portuguese hospital. Materials and methods: We retrospectively analysed 2930 imaging requests ordered during May 2022 by physicians at our hospital, including ultrasound, computed tomography and magnetic resonance. Data were categorized based on the completeness of the provided information (adequately filled out/incomplete/absent), the origin of the request (outpatient consultation; outpatient clinic; inpatient; emergency), requested examination, and evaluated anatomical region. The association between variables was assessed using Pearson’s Chi-square analysis. Results: Of the 2930 imaging examination requests, 71.4% were accompanied by adequately filled clinical information, 27.3% of the requests were incompletely filled, and 1.3% were lacking information. The most frequently requested examination was computed tomography comprising 68.1% of total requests. Significant associations (p < 0.05) were identified between the adequacy of clinical information completion and the requested imaging method, as well as between the origin of the examination request and the completeness of the clinical information and which information was missing. Clinical information was most frequently adequately filled in requests originating from outpatient consultation in 73.4%. Discussion: The fact that at our hospital not all requests are accompanied by adequately filled clinical information shows that there is room to optimize current practices. Understanding the factors impacting its adequate completion allows us to develop approaches aimed at optimizing available resources. Some of the implemented measures include awareness and training programs as well as the adoption of facilitating electronic information systems. Furthermore, fostering open communication between radiologists and clinicians is crucial. Conclusion: Our findings underscore the need for enhanced communication and training in the imaging request process to improve the quality of health care provided at our hospital.