Difference between revisions of "Basics"

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→‎Pathology reports: more to main article Pathology reports -- trim significantly
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==Pathology reports==
==Pathology reports==
The key point in report writing is that the report should be precise, complete and easy-to-understand. Many pathology reports are misunderstood by surgeons; one study suggests that it is 30%!<ref name=pmid10888781>{{Cite journal  | last1 = Powsner | first1 = SM. | last2 = Costa | first2 = J. | last3 = Homer | first3 = RJ. | title = Clinicians are from Mars and pathologists are from Venus. | journal = Arch Pathol Lab Med | volume = 124 | issue = 7 | pages = 1040-6 | month = Jul | year = 2000 | doi = 10.1043/0003-9985(2000)1241040:CAFMAP2.0.CO;2 | PMID = 10888781 }}</ref>
{{Main|Pathology reports}}
The key point in report writing is that the report should be precise, complete and easy-to-understand.  


===Standards===
===Standards===
Based on a PubMed search,<ref>URL: [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=PureSearch&db=PubMed&details_term=standardization,%20surgical%20pathology%20report Pubmed search for ''standardization, surgical pathology report'']. </ref> the first papers on the topic of standards were written in 1992!<ref name=pmid1574498>{{cite journal |author=Rosai J, Bonfiglio TA, Corson JM, ''et al.'' |title=Standardization of the surgical pathology report |journal=Mod. Pathol. |volume=5 |issue=2 |pages=197–9 |year=1992 |month=March |pmid=1574498 |doi= |url=}}</ref><ref name=pmid1574486>{{cite journal |author=Frable WJ, Kempson RL, Rosai J |title=Quality assurance and quality control in anatomic pathology: standardization of the surgical pathology report |journal=Mod. Pathol. |volume=5 |issue=2 |pages=102a–102b |year=1992 |month=March |pmid=1574486 |doi= |url=}}</ref>
There is no universal standard; however, there is a push to standardize by the ''Association of Directors of Anatomic and Surgical Pathology'',<ref>URL: [http://www.adasp.org/papers/position/Standardization.htm http://www.adasp.org/papers/position/Standardization.htm]</ref> among others.
There is no universal standard; however, there is a push to standardize by the ''Association of Directors of Anatomic and Surgical Pathology'',<ref>URL: [http://www.adasp.org/papers/position/Standardization.htm http://www.adasp.org/papers/position/Standardization.htm]</ref> among others.
Standards lead to uniformity and consistency.<ref name=pmid7878300>{{cite journal |author=Leslie KO, Rosai J |title=Standardization of the surgical pathology report: formats, templates, and synoptic reports |journal=Semin Diagn Pathol |volume=11 |issue=4 |pages=253–7 |year=1994 |month=November |pmid=7878300 |doi= |url=}}</ref>
Something close to a standard is laid-out in by Goldsmith et al.<ref name=pmid18834219>{{Cite journal  | last1 = Goldsmith | first1 = JD. | last2 = Siegal | first2 = GP. | last3 = Suster | first3 = S. | last4 = Wheeler | first4 = TM. | last5 = Brown | first5 = RW. | title = Reporting guidelines for clinical laboratory reports in surgical pathology. | journal = Arch Pathol Lab Med | volume = 132 | issue = 10 | pages = 1608-16 | month = Oct | year = 2008 | doi = 10.1043/1543-2165(2008)132[1608:RGFCLR]2.0.CO;2 | PMID = 18834219 }}</ref>


====Checklists====
====Checklists====
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Surgeons know that checklists work and that they save lives.<ref name=pmid19158173>{{cite journal |author=Soar J, Peyton J, Leonard M, Pullyblank AM |title=Surgical safety checklists |journal=BMJ |volume=338 |issue= |pages=b220 |year=2009 |pmid=19158173 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=19158173}}</ref>
Surgeons know that checklists work and that they save lives.<ref name=pmid19158173>{{cite journal |author=Soar J, Peyton J, Leonard M, Pullyblank AM |title=Surgical safety checklists |journal=BMJ |volume=338 |issue= |pages=b220 |year=2009 |pmid=19158173 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=19158173}}</ref>
Pilots have been using checklists since the 1930s.
Pilots have been using checklists since the 1930s.
An excellent book about checklists is: ''The checklist manifesto'' by Harvard surgeon Dr. Atul Gawande.<ref>Gawande A. The checklist manifesto: How to get things right. Metropolitan Books. 2009. URL: [http://www.amazon.com/dp/0805091742 http://www.amazon.com/dp/0805091742]. ISBN-13 978-0805091748.</ref>


===Standard diagnostic notation===
===Standard diagnostic notation===
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