Difference between revisions of "Pathology requisitions"
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**Elements of requisitions, such as 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> | **Elements of requisitions, such as 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== | |||
*Date. | *Date. | ||
*Patient identifiers. | *Patient identifiers. | ||
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*[[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]] - 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> | ||
==Standardization of requisitions== | |||
Standardization facilitates analysis work, both with respect to (1) quality of care, and (2) pathophysiology of disease. | Standardization facilitates analysis work, both with respect to (1) quality of care, and (2) pathophysiology of disease. | ||
It 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> | It 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=== | |||
*PSA ____. | *PSA ____. | ||
*Clinical T stage/DRE examination: ___. | *Clinical T stage/DRE examination: ___. | ||
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*Additional clinical information: ___. | *Additional clinical 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)]. | ||
Revision as of 15:45, 12 April 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 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.
- Sumitting clinic/operating room.
- Clinical history - is considered a necessity and may be a legal requirement.[3][4]
Standardization of requisitions
Standardization facilitates analysis work, both with respect to (1) quality of care, and (2) pathophysiology of disease. It 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
- PSA ____.
- Clinical T stage/DRE examination: ___.
- 5-Alpha inhibitor use: Yes/No.
- Previous biopsy: Yes/No.
- Prior radiation therapy: Yes/No.
- Prostate measurements: SAG ___, AP ___, TRANS ___.
- Prostate volume: ___.
- PSA density ___.
- Additional clinical 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.