Audit on the compliance rate of completion of radiology request forms for CT–brain in Colombo North Teaching Hospital (CNTH), Sri Lanka

Accurate completion of radiology request forms (RRFs) is vital for effective communication between clinicians and radiologists, particularly in high-stakes imaging such as CT-brain studies. Globally, poor RRF compliance has been linked to diagnostic delays and increased radiation exposure. At Colombo North Teaching Hospital (CNTH), incomplete CT-brain RRFs—especially during off-hours—have raised concerns regarding diagnostic accuracy and patient safety. This audit aimed to assess compliance with mandatory fields in CT-brain RRFs at CNTH, identify documentation gaps, and inform targeted interventions to enhance radiological communication and patient care. A retrospective audit of 262 CT-brain RRFs from January to March 2021 was conducted at CNTH. Every third form was sampled, and data were assessed using a standardized 12-field checklist covering demographic, administrative, and clinical information. Compliance was categorized as high (>95%), moderate (80–90%), or low (<50%). Descriptive statistics were used to report field-wise compliance. Ethical approval and institutional permissions were obtained, and data confidentiality was strictly maintained. Administrative fields demonstrated high compliance: Patient name, Ward number, BHT detail, and Date were completed in over 98% of forms. Moderate compliance (80–90%) was observed for Age, Sex, Requesting doctor’s signature, and Legibility. In contrast, clinical fields showed poor compliance: History (45.8%), Urgency (51.5%), Probable diagnosis (35.9%), and Consultant name (24.1%). Only 6.5% of forms were fully completed. These disparities suggest a prioritization of logistical data over essential clinical context. This audit identified significant lapses in the completion of clinical information on CT-brain RRFs at CNTH, jeopardizing diagnostic quality and patient safety. The findings support the implementation of targeted, context-appropriate interventions such as standardized request forms and interdisciplinary training. Future audits should evaluate the impact of such interventions on compliance rates and patient outcomes.