Difference between revisions of "Pathology requisitions"

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*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==
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*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>
*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===
===Prostate biopsies - clinical history checklist===
*PSA ____.
*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 36: Line 53:
*[[Quality]].
*[[Quality]].
*[[Pathology reports]].
*[[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

See also

References

  1. ↑ 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.
  2. ↑ Duggan MA and Trotter T. "Alberta Health Services: Anatomical Pathology Quality Assurance Plan". Canadian Journal of Pathology. 2016;8(3):10-35.
  3. ↑ 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.
  4. ↑ R.R.O. 1990, Reg. 965, s. 31 (1). URL: http://www.ontario.ca/laws/regulation/900965#BK23. Accessed on: 18 December 2015.
  5. ↑ 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.
  6. ↑ Gawande A. The checklist manifesto: How to get things right. Metropolitan Books. 2009. URL: http://www.amazon.com/dp/0805091742. ISBN-13 978-0805091748.
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