Difference between revisions of "Pathology requisitions"
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'''Pathology requisitions''' are the things that come with | '''Pathology requisitions''' are the things that come with [[pathology]] specimens. They contain a large amount of information and provide context. | ||
==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> | |||
**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== | ||
| Line 6: | Line 10: | ||
*Source of specimen. | *Source of specimen. | ||
*Submitting physican. | *Submitting physican. | ||
* | *Submitting clinic/operating room. | ||
*[[Clinical_history#Clinical_history_and_pathology|Clinical history]] - | *[[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: ___. | ||
===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=== | ===Colonoscopy=== | ||
| Line 27: | Line 52: | ||
==See also== | ==See also== | ||
*[[Quality]]. | *[[Quality]]. | ||
*[[Pathology reports]]. | |||
*[[CAP checklists]]. | |||
==References== | ==References== | ||
Latest revision as of 21:06, 8 June 2017
Pathology requisitions are the things that come with pathology specimens. They contain a large amount of information and provide context.
General
- Requisitions are a formal form of communication between healthcare providers and have implications in the quality of care.[1]
- Elements of requisitions, such as the completeness of the clinical history, may be audited as part of a quality program.[2]
Information typically found on requisitions
- Date.
- Patient identifiers.
- Source of specimen.
- Submitting physican.
- Submitting clinic/operating room.
- Clinical history - considered a necessity and may be a legal requirement.[3][4]
Standardization of requisitions
Standardization of requsitions:
- 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.[5][6]
Prostate biopsies - clinical history checklist
- PSA ____ ng/ml.
- Clinical T stage/DRE examination: ___.
- 5-Alpha inhibitor use: Yes/No.
- Previous biopsy: Yes/No.
- Prior radiation therapy: Yes/No.
- Prostate measurements: SAG ___ cm, AP ___ cm, TRANS ___ cm.
- Prostate volume: ___ cm3.
- PSA density ___ ng/ml2.
- Additional clinical information: ___.
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
- Colonoscopy reporting form - BC Cancer Agency (bccancer.bc.ca).
- Colonoscopy reporting form - Intructions - BC Cancer Agency (bccancer.bc.ca).
See also
References
- ↑ Benard, M.; Bouaud, J.; Marsault, C.; Boudghene, F.; Carette, MF.; Séroussi, B. (2015). "Diagnostic imaging requisition quality when using an electronic medical record: a before-after study.". Stud Health Technol Inform 210: 364-8. PMID 25991167.
- ↑ Duggan MA and Trotter T. "Alberta Health Services: Anatomical Pathology Quality Assurance Plan". Canadian Journal of Pathology. 2016;8(3):10-35.
- ↑ Nakhleh, RE.; Gephardt, G.; Zarbo, RJ. (Jul 1999). "Necessity of clinical information in surgical pathology.". Arch Pathol Lab Med 123 (7): 615-9. doi:10.1043/0003-9985(1999)123<0615:NOCIIS>2.0.CO;2. PMID 10388918.
- ↑ R.R.O. 1990, Reg. 965, s. 31 (1). URL: http://www.ontario.ca/laws/regulation/900965#BK23. Accessed on: 18 December 2015.
- ↑ Soar J, Peyton J, Leonard M, Pullyblank AM (2009). "Surgical safety checklists". BMJ 338: b220. PMID 19158173. http://bmj.com/cgi/pmidlookup?view=long&pmid=19158173.
- ↑ Gawande A. The checklist manifesto: How to get things right. Metropolitan Books. 2009. URL: http://www.amazon.com/dp/0805091742. ISBN-13 978-0805091748.