Pathology reports

Sign out is the finalization of a case. The term comes from when one used to actually sign the reports.

Rules

• Diagnostic line should end with a period.

Report sections/elements

Addendum

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

Amendment

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

Dealing with errors

• 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

• Basics.
• MEDITECH.