Evaluation of laboratory request forms for incomplete data at a rural tertiary hospital in Nigeria

Abstract

Objective: To determine type and frequency of omission of relevant data on laboratory request forms at a rural tertiary Hospital in Nigeria. Methods: A total of 2,362 laboratory request forms sent to the Pathology Department of Igbinedion University Teaching Hospital Okada within a 10 month period were scrutinized for specific parameters. The forms were evaluated to determine what section was incorrect and/or incomplete and the frequency of such errors. Results: Data mostly omitted was patient's age, observed in 48.3% of request forms reviewed. Complete documentation was only observed in respect to patients name and signature of attending physician. The name of the attending physician, however, was missing in 19.8% of forms audited. Information regarding patient's gender and location (ward) in the hospital was absent in 1.1%, and 20.1% cases respectively. 151(6.4%) of audited forms were void of working diagnosis, while type of clinical sample was not documented in 2.7% of laboratory request forms evaluated. Conclusions: Data mostly omitted in laboratory forms audited was patient's age, (48.3%) followed by location of patient (20.1%). Incomplete data on laboratory request forms can lead to misdiagnosis and mismanagement of patients. Renewed emphasis on relevance of completeness of data on laboratory request test forms is strongly advocated.