Difference between revisions of "Pathology requisitions"

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Pathology requisitions (view source)

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'''Pathology requisitions''' are the things that come with to the [[pathology]] specimens.  They contain a large amount of information.
'''Pathology requisitions''' are the things that come with [[pathology]] specimens.  They contain a large amount of information and provide context.


==General==
==General==
*Requisitions are a formal form of communication between healthcare providers and have implications in the [[quality]] of care.<ref name=pmid25991167>{{Cite journal  | last1 = Benard | first1 = M. | last2 = Bouaud | first2 = J. | last3 = Marsault | first3 = C. | last4 = Boudghene | first4 = F. | last5 = Carette | first5 = MF. | last6 = Séroussi | first6 = B. | title = Diagnostic imaging requisition quality when using an electronic medical record: a before-after study. | journal = Stud Health Technol Inform | volume = 210 | issue =  | pages = 364-8 | month =  | year = 2015 | doi =  | PMID = 25991167 }}</ref>
*Requisitions are a formal form of communication between healthcare providers and have implications in the [[quality]] of care.<ref name=pmid25991167>{{Cite journal  | last1 = Benard | first1 = M. | last2 = Bouaud | first2 = J. | last3 = Marsault | first3 = C. | last4 = Boudghene | first4 = F. | last5 = Carette | first5 = MF. | last6 = Séroussi | first6 = B. | title = Diagnostic imaging requisition quality when using an electronic medical record: a before-after study. | journal = Stud Health Technol Inform | volume = 210 | issue =  | pages = 364-8 | month =  | year = 2015 | doi =  | PMID = 25991167 }}</ref>
**Elements of requisitions, such as the completeness of the clinical history, may be audited as part of a quality program.<ref>Duggan MA and Trotter T. "Alberta Health Services: Anatomical Pathology Quality Assurance Plan". Canadian Journal of Pathology. 2016;8(3):10-35. </ref>


===Information typically found on requisitions===
==Information typically found on requisitions==
*Date.
*Date.
*Patient identifiers.
*Patient identifiers.
*Source of specimen.
*Source of specimen.
*Submitting physican.
*Submitting physican.
*Sumitting clinic/operating room.
*Submitting clinic/operating room.
*[[Clinical_history#Clinical_history_and_pathology|Clinical history]] - is considered a necessity and may be a legal requirement.<ref name=pmid10388918>{{Cite journal  | last1 = Nakhleh | first1 = RE. | last2 = Gephardt | first2 = G. | last3 = Zarbo | first3 = RJ. | title = Necessity of clinical information in surgical pathology. | journal = Arch Pathol Lab Med | volume = 123 | issue = 7 | pages = 615-9 | month = Jul | year = 1999 | doi = 10.1043/0003-9985(1999)123<0615:NOCIIS>2.0.CO;2 | PMID = 10388918 }}</ref><ref name=reg965>R.R.O. 1990, Reg. 965, s. 31 (1). URL: [http://www.ontario.ca/laws/regulation/900965#BK23 http://www.ontario.ca/laws/regulation/900965#BK23]. Accessed on: 18 December 2015.</ref>
*[[Clinical_history#Clinical_history_and_pathology|Clinical history]] - considered a necessity and may be a legal requirement.<ref name=pmid10388918>{{Cite journal  | last1 = Nakhleh | first1 = RE. | last2 = Gephardt | first2 = G. | last3 = Zarbo | first3 = RJ. | title = Necessity of clinical information in surgical pathology. | journal = Arch Pathol Lab Med | volume = 123 | issue = 7 | pages = 615-9 | month = Jul | year = 1999 | doi = 10.1043/0003-9985(1999)123<0615:NOCIIS>2.0.CO;2 | PMID = 10388918 }}</ref><ref name=reg965>R.R.O. 1990, Reg. 965, s. 31 (1). URL: [http://www.ontario.ca/laws/regulation/900965#BK23 http://www.ontario.ca/laws/regulation/900965#BK23]. Accessed on: 18 December 2015.</ref>


===Standardization of requisitions===
==Standardization of requisitions==
====Prostate biopsies====
Standardization of requsitions:
*PSA ____.
*Facilitates analysis work, both with respect to: (1) quality of care, and (2) pathophysiology of disease.
*Likely facilitates a higher standard of care, based on the significant body of research on checklist use inside and outside of medicine.<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><ref name=gawande>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>
 
===Prostate biopsies - clinical history checklist===
*PSA ____ ng/ml.
*Clinical T stage/DRE examination: ___.
*Clinical T stage/DRE examination: ___.
*5-Alpha inhibitor use: Yes/No.
*5-Alpha inhibitor use: Yes/No.
*Previous biopsy: Yes/No.
*Previous biopsy: Yes/No.
*Prior radiation therapy: Yes/No.
*Prior radiation therapy: Yes/No.
*Prostate measurements: SAG ___, AP ___, TRANS ___.
*Prostate measurements: SAG ___ cm, AP ___ cm, TRANS ___ cm.
**Prostate volume: ___.
**Prostate volume: ___ cm<sup>3</sup>.
*[[PSA density]] ___.
*[[PSA density]] ___ ng/ml<sup>2</sup>.
*Additional clinical information: ___.
*Additional clinical information: ___.


====Colonoscopy====
===Urinary bladder biopsies/TURBTs - clinical history checklist===
*History of bladder tumour: No/Yes.
*BCG treatment: Yes/No.
*Erythema: Yes/No.
*Definite tumour: Yes/No.
**Location of tumour: ___.
**Clinical stage: ___.
*Other clinical information: ___.
 
===Lung mass - clinical history checklist===
*Previous lung biopsy: No/Yes.
*History of cancer: No/Yes - primary site _______.
*Suspected cancer: No/Yes
**If ''Yes'': primary lung/metastasis, clinical stage _______.
*Exposure history, e.g. smoking: _______.
*Other relevant information: _______.
 
===Colonoscopy===
*[http://www.bccancer.bc.ca/screening/Documents/COLON_Form-ColonoscopyReportingFormPage01.pdf Colonoscopy reporting form - BC Cancer Agency (bccancer.bc.ca)].
*[http://www.bccancer.bc.ca/screening/Documents/COLON_Form-ColonoscopyReportingFormPage01.pdf Colonoscopy reporting form - BC Cancer Agency (bccancer.bc.ca)].
*[http://www.bccancer.bc.ca/screening/Documents/COLON_Instructions-ColonoscopyReportingFormInstructions.pdf Colonoscopy reporting form - Intructions - BC Cancer Agency (bccancer.bc.ca)].
*[http://www.bccancer.bc.ca/screening/Documents/COLON_Instructions-ColonoscopyReportingFormInstructions.pdf Colonoscopy reporting form - Intructions - BC Cancer Agency (bccancer.bc.ca)].
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==See also==
==See also==
*[[Quality]].
*[[Quality]].
*[[Pathology reports]].
*[[CAP checklists]].


==References==
==References==
Michael
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