Difference between revisions of "Pathology reports"

From Libre Pathology
Jump to navigation Jump to search
(tweak language)
Line 3: Line 3:
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==
Line 10: Line 10:
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>
Line 18: Line 18:
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].


Pathologists will probably use more checklists in the future... they are deemed effective in a number of places inside and outside of medicine.   
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>
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.
 
An interesting book about checklists in medicine 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===
Line 48: Line 44:


====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.


Revision as of 04:35, 14 July 2015

Pathology reports are what pathologists produce when finishing a case. Sign out is the finalization of a case. This article discusses both.

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, unfortunately, are misunderstood by surgeons; one study suggests that it is 30%![1]

Standards

Based on a PubMed search,[2] the first papers on the topic of standards were written in 1992![3][4]

There is no universal standard; however, there is a push to standardize by the Association of Directors of Anatomic and Surgical Pathology,[5] among others.

Standards appear to lead to uniformity and consistency.[6]

Something close to a standard is laid-out in by Goldsmith et al.[7]

Checklists

Main article: CAP checklists

The College of American Pathologists (CAP) has checklists for cancer - 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.[8] Pilots have been using checklists since the 1930s.[9]Gawande A. The checklist manifesto: How to get things right. Metropolitan Books. 2009. URL: http://www.amazon.com/dp/0805091742. ISBN-13 978-0805091748.</ref>

Standard diagnostic notation

Site, operation/procedure:
- Tissue type diagnosis.


Example:
Gallbladder, cholecystectomy:
- Acute cholecystitis.

Libre Pathology formating recommendations

Diagnosis

  • The tissue type/site usually should be what the clinician submitted it as.
    • Lay terms are preferred in some circumstances (e.g. stomach instead of gastric), as the patients often read their pathology reports.
  • The tissue type should be the first thing in the diagnostic line if it is not obvious from the diagnosis, e.g. gastric body-type mucosa.
  • If several diagnoses are made, the most clinically important diagnosis should be listed first.
  • Each diagnostic line should end with a period or semicolon.
    • Punctuation experts are somewhat divided on what to do here.[10][11]
    • 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.[12]
    • Negative and without are preferred.

Abbreviations

  • 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.

Microscopic

AKA microscopy.
  • Describes how the tissue looks under the microscope.[13]

Notes:

  • One should not assume it is going to be read by the clinician.
    • If it is essential to read, a comment in the diagnosis section, that says see microscopic, is advisable.
  • Immunostains should be reported as a comment in the diagnosis section.
    • Many labs report IHC in the microscopic section.[7]
  • Internal reviews/consults should likewise not be found here; they should be in a comment in the diagnosis section.

Report sections/elements

Addendum

  • Formally called report addendum.
  • Used to add material to the report.
  • Generally, the new material should not substantially contradict the opinion offered by the report.

Amendment

  • Formally report amendment.
  • Used to change the diagnosis or significant interpretations in the report.

Dealing with errors

Main article: Quality
  • Opinion is split on whether reports should be amended or addended.

Addendum versus amendment for errors

Addendum:

  • PROS:
    • Report has not been changed per se.
  • CONS:
    • Report confusing - as it contains contradictory information.
    • Risk of misinterpretation higher - as the addendum may not be read.

Amendment:

  • PROS:
    • Revised diagnosis is apparent.
  • CONS:
    • Change in report may not be apparent -- depends on information management system.

See also

References

  1. ↑ Powsner, SM.; Costa, J.; Homer, RJ. (Jul 2000). "Clinicians are from Mars and pathologists are from Venus.". Arch Pathol Lab Med 124 (7): 1040-6. doi:10.1043/0003-9985(2000)1241040:CAFMAP2.0.CO;2. PMID 10888781.
  2. ↑ URL: Pubmed search for standardization, surgical pathology report.
  3. ↑ Rosai J, Bonfiglio TA, Corson JM, et al. (March 1992). "Standardization of the surgical pathology report". Mod. Pathol. 5 (2): 197–9. PMID 1574498.
  4. ↑ Frable WJ, Kempson RL, Rosai J (March 1992). "Quality assurance and quality control in anatomic pathology: standardization of the surgical pathology report". Mod. Pathol. 5 (2): 102a–102b. PMID 1574486.
  5. ↑ URL: http://www.adasp.org/papers/position/Standardization.htm. Accessed on: 6 September 2012.
  6. ↑ Leslie KO, Rosai J (November 1994). "Standardization of the surgical pathology report: formats, templates, and synoptic reports". Semin Diagn Pathol 11 (4): 253–7. PMID 7878300.
  7. ↑ 7.0 7.1 Goldsmith, JD.; Siegal, GP.; Suster, S.; Wheeler, TM.; Brown, RW. (Oct 2008). "Reporting guidelines for clinical laboratory reports in surgical pathology.". Arch Pathol Lab Med 132 (10): 1608-16. doi:10.1043/1543-2165(2008)132[1608:RGFCLR]2.0.CO;2. PMID 18834219.
  8. ↑ 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.
  9. ↑ Cite error: Invalid <ref> tag; no text was provided for refs named gawande
  10. ↑ URL: phttp://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html. Accessed on: 10 January 2014.
  11. ↑ URL: http://www.ossweb.com/article-bullets.html. Accessed on: 10 January 2014.
  12. ↑ Renshaw, MA.; Gould, EW.; Renshaw, A. (Sep 2010). "Just say no to the use of no: alternative terminology for improving anatomic pathology reports.". Arch Pathol Lab Med 134 (9): 1250-2. doi:10.1043/2010-0031-SA.1. PMID 20807042.
  13. ↑ URL: http://www.cancer.gov/cancertopics/factsheet/detection/pathology-reports. Accessed on: 24 April 2014.

External links

Retrieved from "https://librepathology.org/w/index.php?title=Pathology_reports&oldid=38810"