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 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%![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 interesting book about checklists in medicine 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.
Onlinepathology 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.
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
- Describes how the tissue looks under the microscope.[12]
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.
- 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
- 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.
- ↑ URL: phttp://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html. Accessed on: 10 January 2014.
- ↑ URL: http://www.ossweb.com/article-bullets.html. Accessed on: 10 January 2014.
- ↑ URL: http://www.cancer.gov/cancertopics/factsheet/detection/pathology-reports. Accessed on: 24 April 2014.