Pathology reports
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 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%![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 lead to uniformity and consistency.[6]
Something close to a standard is laid-out in by Goldsmith et al.[7]
Checklists
The College of American Pathologists (CAP) has checklists for cancer - 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. Surgeons know that checklists work and that they save lives.[8] Pilots have been using checklists since the 1930s.
An excellent book about checklists is: The checklist manifesto by Harvard surgeon Dr. Atul Gawande.[9]
Standard diagnostic notation
Site, operation/procedure:
- Tissue type diagnosis.
Example:
Gallbladder, cholecystectomy:
- Acute cholecystitis.
VL formating recommendations
- 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 offered by 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
References
- ↑ 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.
- ↑ URL: Pubmed search for standardization, surgical pathology report.
- ↑ Rosai J, Bonfiglio TA, Corson JM, et al. (March 1992). "Standardization of the surgical pathology report". Mod. Pathol. 5 (2): 197–9. PMID 1574498.
- ↑ 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.
- ↑ URL: http://www.adasp.org/papers/position/Standardization.htm
- ↑ 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.
- ↑ 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.
- ↑ 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.