Pathology requisitions

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.
  • Elements of requisitions, such as the completeness of the clinical history, may be audited as part of a quality program.

Information typically found on requisitions

• Date.
• Patient identifiers.
• Source of specimen.
• Submitting physican.
• Submitting clinic/operating room.
• Clinical history - considered a necessity and may be a legal requirement.

Standardization of requisitions

Standardization of requsitions:

• Facilitates analysis work, both with respect to: (1) quality of care, and (2) pathophysiology of disease.
• Likely facilitates a higher standard of care, based on the significant body of research on checklist use inside and outside of medicine.

Prostate biopsies - clinical history checklist

• PSA ____ ng/ml.
• Clinical T stage/DRE examination: ___.
• 5-Alpha inhibitor use: Yes/No.
• Previous biopsy: Yes/No.
• Prior radiation therapy: Yes/No.
• Prostate measurements: SAG ___ cm, AP ___ cm, TRANS ___ cm.
  • Prostate volume: ___ cm³.
• PSA density ___ ng/ml².
• Additional clinical information: ___.

Urinary bladder biopsies/TURBTs - clinical history checklist

• History of bladder tumour: No/Yes.
• BCG treatment: Yes/No.
• Erythema: Yes/No.
• Definite tumour: Yes/No.
  • Location of tumour: ___.
  • Clinical stage: ___.
• Other clinical information: ___.

Lung mass - clinical history checklist

• Previous lung biopsy: No/Yes.
• History of cancer: No/Yes - primary site _______.
• Suspected cancer: No/Yes
  • If Yes: primary lung/metastasis, clinical stage _______.
• Exposure history, e.g. smoking: _______.
• Other relevant information: _______.

Colonoscopy

• Colonoscopy reporting form - BC Cancer Agency (bccancer.bc.ca).
• Colonoscopy reporting form - Intructions - BC Cancer Agency (bccancer.bc.ca).

See also

• Quality.
• Pathology reports.
• CAP checklists.