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%!

Standards

Based on a PubMed search, the first papers on the topic of standards were written in 1992!

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

Standards lead to uniformity and consistency.

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

Checklists

Main article: CAP 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. 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.

Standard diagnostic notation

Site, operation/procedure:
- Tissue type diagnosis.

Example:
Gallbladder, cholecystectomy:
- Acute cholecystitis.

Onlinepathology formating recommendations

• Diagnostic line should end with a period.
• Abbreviations should not be used, e.g. LEEP should be written-out as loop electrosurgical excision procedure.
• 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.
• 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.

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

• Basics.
• MEDITECH.