The Role of Clinical History Collected by Diagnostic Imaging Staff in Interpreting of Imaging Examinations

Requisitions for diagnostic imaging (DI) studies may occasionally contain incomplete, or lack any, clinical information. The value of technologist notes, provided in addition to the requisitions, for interpreting DI examinations has not yet been reported. The purpose of this study is to evaluate if the addition of clinical information in the form of technologist notes assists in interpreting DI examinations and if the impact of these notes depends on the completeness of medical history provided by the referring physician.

The completeness of clinical information in 250 requisitions and the effect of a technologist's notes on radiological interpretation were recorded. The chi-square test was used to evaluate the distribution of outcomes.

Technologist notes were important for interpreting a DI examinations in 69.2% of cases and not important in 30.8%. The notes were significantly more useful for reading radiographic examinations than ultrasound (US) examinations; 52.8% of the requisitions contained full, 25.6% incomplete, and 21.6% did not contain any medical history. Requisitions for ultrasound examinations contained a full medical history more frequently than those for radiographic examinations. The usefulness of technologist notes for both radiographic and US examinations was not different for groups with full, incomplete, or absent medical history.

Technologist notes were important for interpreting DI examinations in more than 2/3 of the cases and were more useful for reading of radiographic than US examinations. Their usefulness did not depend on the degree of completeness of patient history provided in the requisition. Therefore, the addition of technologist notes to clinical information in requisitions is recommended, regardless of medical history provided by the referring physician.