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ABSTRACT
Background
The incompleteness of laboratory request forms (LRFs) has been a recurring problem encountered in the Haematology laboratory. The LRF is an important two-way communication tool between clinicians and laboratory personnel (i.e. pathologists, scientists and technologists) in the laboratory. The incomplete filling of LRFs pose a challenge as they may lack crucial information. For example, sex and age are essential when interpreting test results as this requires a comparison of the patient results to reference ranges in order to arrive at an accurate diagnosis. The full blood count (FBC) test with or without a differential (FBC±D) count is a commonly requested test that measures the quantity and quality of the cellular blood components. It is often one of the first tests that are requested in order to identify if further tests are necessary. Therefore, the incomplete FBC±D LRFs can negatively impact patient outcomes. The aim of this study was to evaluate the completeness in filling of the LRFs for the FBC±D test and to evaluate the capturing of these LRFs submitted to the Dr George Mukhari Academic Laboratory (DGMAL) of the National Health Laboratory Service (NHLS).
Method
This was a cross-sectional descriptive study of approximately 384 LRFs submitted for the FBC±D test at the DGMAL for the period of 1 January to 31 December 2023. Laboratory request forms were assessed for the completeness in filling of all sections, namely patient information including details of private medical aid if applicable, hospital details, specimen information and the sender’s information. The NHLS laboratory information system, TrakCare® was accessed to check if all the information on these LRFs were correctly captured. The data collected was analysed using the Stata Version 18 software and a p-value of 0.05 was considered statistically significant.
Result
The most consistently completed parameters on the LRFs were the patient’s surname (99.22%) and first name (98.96%), the name of the hospital/clinic (98.96%) and the health care worker’s Health Professions Council of South Africa/South African Nursing Council number (96.88%). The parameters that were the most correctly captured on TrakCare were the surname (98.96%) and first name (98.7%) of the patient, the name of the hospital/clinic (98.44%) and the sex of the patient (95.05%).
Conclusion
The study revealed that none of the 384 forms reviewed were completely filled and none of the forms were correctly captured. The introduction of an order entry system (electronic platform) would help improve the form filling patterns in the health sector and ensure that all information is correctly reflected.