Clinical History on Emergency X-Ray Referrals

Published 17 September 2018. Last updated 1 October 2018.

Incomplete clinical history information on emergency x-ray referrals can lead to insufficient imaging, missed pathologies, longer time spent in emergency and higher radiation doses. This project aims to ensure that a concise clinical history is included on every emergency x-ray referral at the Cowra Health Service. This will enable accurate imaging and diagnostic reporting and lead to the best possible outcome for patients.


By February 2018, 100% of electronic emergency x-ray referrals at the Cowra Health Service will include five clinical history criteria relevant to the requested examination. The five criteria are: site (body part); side (i.e. left, right, central); time of injury or presenting condition; mechanism (how it happened); and differential diagnosis (what is the expected finding or clinical question?).


The benefits of sufficient clinical detail include the following.

  • Justification for the performance of the imaging examination, confirming appropriate choice of examination and modality.
  • Radiation doses are kept as low as possible (ALARA principle). High quality information provided in a referral allows the radiographer and clinical radiologist to ensure that medical radiation is justified and kept to a minimum.
  • Reduced medical imaging incidents.
  • Increased accuracy on radiology reports and less risk of missed pathology.


Lack of adequate clinical history on emergency x-ray referrals is common across all twenty-two imaging departments within the Western NSW Local Health District despite being a requirement of the area’s 'Correct Patient, Procedure and Site' policy.

When ordering an electronic x-ray, clinical history is a mandatory entry but the system will accept a simple full-stop to override this requirement. Retrospective data collated over eight months showed that on average, only two out of five required clinical history criteria were routinely included.

Pre-intervention surveys were given to all staff in the Cowra emergency department who order x-rays electronically. The results showed that time, IT issues and a lack of knowledge of clinical history requirements were the main impediments to providing a complete clinical history.

Providing a complete clinical history justifies the imaging request and gives the radiographer signposts to help them produce the most accurate imaging; match the history with the patient's version of events; keeps the number of images to a minimum and therefore radiation doses as low as reasonably achievable (ALARA principle); and prevents return trips to the x-ray department, therefore saving time.

The five criteria chosen for this project were site, side, timing, mechanism, and differential diagnosis. These criteria are important because:

  • information about the site and side helps to lower the risk of imaging the wrong body part and pinpoints the region under examination
  • timing of an event can produce different pathological appearances on x-rays
  • mechanism of an injury or event can produce different pathologies and therefore different x-ray projections chosen
  • differential diagnosis helps the radiographer and reporting radiologist understand what is being looked at so they can provide the most accurate imaging and consequent report.


Pre-intervention survey

  • Time limitations, IT issues and lack of knowledge of clinical history requirements were perceived by staff as obstacles.

Education of staff on clinical history requirements

  • A staff education PowerPoint demonstration was developed for all emergency staff and delivered by the Chief Radiographer.
  • One-on-one sessions were provided ensure that all staff had the opportunity to see the demonstration.
  • Content included an explanation of the project, the necessary five criteria, their significance and purpose, the current low average inclusion rate of 2.1 criteria, the consequences of not including them. and examples of how clinical history entries should read.
  • Laminated cards were developed as a reference and reminder to 'Aim for 5'.
  • Emergency x-ray referrals were consequently collated post education for four weeks.
  • Reference guide cards were made and placed in strategic positions near computers as a reminder.
  • Referrals continued to be collated for a total of four months.


Sustained – The project has been implemented and is sustained in standard business.


November 2016 – February 2018

Implementation site

Cowra Health Service, WNSWLHD


Clinical Excellence Commision Clinical Leadership Program


  • 100% staff response to survey
  • 95% of staff underwent education
    • immediate increase in number of criteria included
    • positive response with both interventions
    • average dropped post interventions
    • for some staff it made no difference

Following each educational intervention, there was an increase of the average number of criteria, followed by a small fall, with a peak of 3.6 criteria.

Due to the unexpected absence of the project leader for eight weeks, the last proposed intervention was not implemented, and a further fall in criteria inclusion followed. Education had a positive impact on clinical history criteria inclusion. The average number of included criteria following education was 3.3. Nurses were found to have the least knowledge of what ought to be included (the least training historically) and had the most positive and sustained response to education.

Lessons learnt

  • Engage with clinicians early on and involve them in the process.
  • Identify champions and provide them with support and encouragement.
  • Hold regular team meetings to maintain momentum.
  • Provide encouragement and review regularly to maintain change.


Victoria Williams
Chief Radiographer
Cowra Health Service
Western NSW Local Health District
Phone: 02 6340 9018


Fill in our feedback form to find out more about this project or get in touch with the project manager.

Is this your project?

Fill in our feedback form to update your story or contact details.

Browse similar projects

ReferralRadiologyWestern NSWEmergencyRural and regionalClinical Leadership Program
Back to top