Clinical information on requisitions

Providing clinical information on requisitions should not be delegated to office staff

A group of physician leaders in a health authority recently requested advice from the College regarding the implementation of electronic submission of requisitions for medical imaging and laboratory tests as part of their EHR (electronic health record) development. Their concern was that some clinicians had acknowledged that it was their practice to delegate completion of paper requisitions to clerical staff. The clinicians’ rationale for delegating was that in order to submit electronically, they would have to log in to the system and spend time entering the information themselves, which they felt was inefficient.

Physicians in diagnostic specialties rely on the background clinical narrative provided by referring physicians on requisitions in the same way that clinicians begin their assessment by taking a history. It improves the likelihood of making the correct diagnosis; nothing is more fundamental to medical practice. Providing clinical information on the requisition is a task that cannot reasonably be delegated to clerical staff. Registrants are reminded that the clinical part of a requisition, whether in print or electronic format, is the responsibility of clinicians—nurse practitioners, midwives, or physicians—not medical office assistants.

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