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Difference between revisions of "Pathology reports"
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The term ''sign out'' is from when one used to actually sign the reports. | The term ''sign out'' is from when one used to actually sign the 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> | The key point in report writing is that the report should be precise, complete and easy-to-understand. Many pathology reports, unfortunately, 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> | ||
==Standards== | ==Standards== | ||
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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]. Accessed on: 6 September 2012.</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]. Accessed on: 6 September 2012.</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> | Standards appear to 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> | 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> | ||
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The College of American Pathologists (CAP) has checklists for cancer - [http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=committees%2Fcancer%2Fcancer_protocols%2Fprotocols_index.html&_state=maximized&_pageLabel=cntvwr CAP protocols]. | The College of American Pathologists (CAP) has checklists for cancer - [http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=committees%2Fcancer%2Fcancer_protocols%2Fprotocols_index.html&_state=maximized&_pageLabel=cntvwr CAP protocols]. | ||
It seems likely that pathologists will use more checklists in the future... they are deemed effective in a number of places inside and outside of medicine. Good evidence suggests that surgical checklists reduces adverse events.<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.<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> | |||
Pilots have been using checklists since the 1930s | |||
===Standard diagnostic notation=== | ===Standard diagnostic notation=== | ||
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- Acute cholecystitis. | - Acute cholecystitis. | ||
=='' | ==Formatting recommendations used on ''Libre Pathology''== | ||
===Diagnosis=== | ===Diagnosis=== | ||
*The tissue type/site usually should be what the clinician submitted it as. | *The tissue type/site usually should be what the clinician submitted it as. | ||
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**Punctuation experts are somewhat divided on what to do here.<ref>URL: [http://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html phttp://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html]. Accessed on: 10 January 2014.</ref><ref>URL: [http://www.ossweb.com/article-bullets.html http://www.ossweb.com/article-bullets.html]. Accessed on: 10 January 2014.</ref> | **Punctuation experts are somewhat divided on what to do here.<ref>URL: [http://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html phttp://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html]. Accessed on: 10 January 2014.</ref><ref>URL: [http://www.ossweb.com/article-bullets.html http://www.ossweb.com/article-bullets.html]. Accessed on: 10 January 2014.</ref> | ||
**The advantage of using a period or semicolon is: the end the diagnostic line is clearly marked. | **The advantage of using a period or semicolon is: the end the diagnostic line is clearly marked. | ||
*It is best to avoid ''no'' and ''not'', as these may be lost at transcription or overlooked.<ref>{{Cite journal | last1 = Renshaw | first1 = MA. | last2 = Gould | first2 = EW. | last3 = Renshaw | first3 = A. | title = Just say no to the use of no: alternative terminology for improving anatomic pathology reports. | journal = Arch Pathol Lab Med | volume = 134 | issue = 9 | pages = 1250-2 | month = Sep | year = 2010 | doi = 10.1043/2010-0031-SA.1 | PMID = 20807042 }}</ref> | |||
**''Negative'' and ''without'' are preferred. | |||
====Uncertainty==== | |||
*Uncertainty in reports can be conveyed with various terms. | |||
*There is no standard but the interpretation (by clinicians and pathologists) of various phrases have been compared by Lindley ''et al.'' using a scale of 0 (uncertain) to 100 (certain):<ref name=pmid24939143>{{Cite journal | last1 = Lindley | first1 = SW. | last2 = Gillies | first2 = EM. | last3 = Hassell | first3 = LA. | title = Communicating diagnostic uncertainty in surgical pathology reports: disparities between sender and receiver. | journal = Pathol Res Pract | volume = 210 | issue = 10 | pages = 628-33 | month = Oct | year = 2014 | doi = 10.1016/j.prp.2014.04.006 | PMID = 24939143 }}</ref> | |||
**''Cannot rule out'' (55) and ''indefinite for ...'' (52) convey the highest level of uncertainty among attending clinicians. | |||
**''Suggestive of ...'' (57) conveys a lesser level of uncertainty. | |||
**''Consistent with ...'' (76) seems to be ignored by many. | |||
====Abbreviations==== | ====Abbreviations==== | ||
*Abbreviations should not be used, e.g. [[LEEP]] should be written-out as ''loop electrosurgical excision procedure''. | *[[Abbreviations]] should not be used, e.g. [[LEEP]] should be written-out as ''loop electrosurgical excision procedure''. | ||
**Patients often read their reports. Abbreviations muddle things. | **Patients often read their reports. Abbreviations muddle things. | ||
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===Amendment=== | ===Amendment=== | ||
*Formally ''report amendment''. | *Formally ''report amendment''. | ||
*Used to change the [[diagnosis]] or significant interpretations in the report. | *Used to change the [[diagnosis]] ''or'' significant interpretations in the report. | ||
==Dealing with errors== | ==Dealing with errors and when to use an amendment== | ||
{{Main|Quality}} | {{Main|Quality}} | ||
=== | *If an addendum would add information to the report that contradicts other information already in the report: it should be an amendment (not an addendum).<ref name=pmid25357114>{{cite journal |authors=Babwah JP, Khalifa M, Rowsell C |title=Analysis of addenda in anatomic pathology as a quality monitoring initiative |journal=Arch Pathol Lab Med |volume=138 |issue=11 |pages=1514–9 |date=November 2014 |pmid=25357114 |doi=10.5858/arpa.2012-0412-OA |url=}}</ref> | ||
It is good practice when amending an report to: | |||
* | * Clearly state the revised diagnosis. | ||
** | * Clearly note that the diagnosis was changed. | ||
* | * Clearly state what the diagnosis was previously. | ||
** | * Have another pathologist confirm the revised diagnosis. | ||
* Communicate directly with the most responsible physician - make them aware of the change. | |||
* Document the communication. | |||
==See also== | ==See also== | ||
*[[Basics]]. | *[[Basics]]. | ||
*[[MEDITECH]]. | *[[MEDITECH]]. | ||
*[[Pathology requisitions]]. | |||
==References== | ==References== | ||