Supporting quality use of referrals

The information provided on an imaging request form has a direct impact on patient care and safety.

Supporting quality use of referrals

Recent changes to the MBS explanatory notes have been made regarding the information to be included on requests for diagnostic imaging providers. Ensuring the form is completed in full and contains key clinical details will allow the provider to understand the context of the request, interpret the results, and provide a clinically appropriate report. Providing sufficient information will also reduce the likelihood of imaging being delayed while further clarification is sought.

It has been reported that less than half of ultrasound request forms contained conclusive information and instructions for the radiologist.1

Key information includes:

  • a clear and legible request that notes the clinical question being addressed (including a clear diagnostic question)
  • identity of the patient
  • identity of the requestor
  • clinical details such as
    • a provisional diagnosis to help determine what conditions should be ruled in and out
    • any instructions for the procedure
    • any red flags (indicators for specific clinical suspicion)
    • relevant history and examination findings
    • results of related biochemical and radiological investigations, such as concentrations, anti-thyroid antibody titres, and previous scan findings, which can assist the radiologist in interpreting test results.
  • information to demonstrate the service meets specific MBS requirements

Inclusion of these details on request forms will increase clinician awareness of high-value tests, minimise radiation exposure, support timely investigation of patients, and promote greater recognition of item descriptor inclusions and exclusions. Additionally, this will also improve the communication between the requestor and the provider.