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Difference between revisions of "Pathology reports"
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====Uncertainty==== | ====Uncertainty==== | ||
*Uncertainty in reports can be conveyed with various terms. | *Uncertainty in reports can be conveyed with various terms. | ||
*There is no standard but the interpretation (by clinicians and pathologists) of various | *There is no standard but the interpretation (by clinicians and pathologists) of various phrases have been compared by Lindley ''et al.'' using a scale of 0 (uncertain) to 100 (certain):<ref name=pmid24939143>{{Cite journal | last1 = Lindley | first1 = SW. | last2 = Gillies | first2 = EM. | last3 = Hassell | first3 = LA. | title = Communicating diagnostic uncertainty in surgical pathology reports: disparities between sender and receiver. | journal = Pathol Res Pract | volume = 210 | issue = 10 | pages = 628-33 | month = Oct | year = 2014 | doi = 10.1016/j.prp.2014.04.006 | PMID = 24939143 }}</ref> | ||
**''Cannot rule out'' (55) and ''indefinite for ...'' (52) convey the highest level of uncertainty among attending clinicians. | **''Cannot rule out'' (55) and ''indefinite for ...'' (52) convey the highest level of uncertainty among attending clinicians. | ||
**''Suggestive of ...'' (57) conveys a lesser level of uncertainty. | **''Suggestive of ...'' (57) conveys a lesser level of uncertainty. | ||
**''Consistent with ...'' (76) seems to be ignored by many. | **''Consistent with ...'' (76) seems to be ignored by many. | ||
====Abbreviations==== | ====Abbreviations==== | ||
*[[Abbreviations]] should not be used, e.g. [[LEEP]] should be written-out as ''loop electrosurgical excision procedure''. | *[[Abbreviations]] should not be used, e.g. [[LEEP]] should be written-out as ''loop electrosurgical excision procedure''. | ||
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===Amendment=== | ===Amendment=== | ||
*Formally ''report amendment''. | *Formally ''report amendment''. | ||
*Used to change the [[diagnosis]] or significant interpretations in the report. | *Used to change the [[diagnosis]] ''or'' significant interpretations in the report. | ||
==Dealing with errors== | ==Dealing with errors and when to use an amendment== | ||
{{Main|Quality}} | {{Main|Quality}} | ||
=== | *If an addendum would add information to the report that contradicts other information already in the report: it should be an amendment (not an addendum).<ref name=pmid25357114>{{cite journal |authors=Babwah JP, Khalifa M, Rowsell C |title=Analysis of addenda in anatomic pathology as a quality monitoring initiative |journal=Arch Pathol Lab Med |volume=138 |issue=11 |pages=1514–9 |date=November 2014 |pmid=25357114 |doi=10.5858/arpa.2012-0412-OA |url=}}</ref> | ||
It is good practice when amending an report to: | |||
* | * Clearly state the revised diagnosis. | ||
** | * Clearly note that the diagnosis was changed. | ||
* | * Clearly state what the diagnosis was previously. | ||
** | * Have another pathologist confirm the revised diagnosis. | ||
* Communicate directly with the most responsible physician - make them aware of the change. | |||
* Document the communication. | |||
==See also== | ==See also== | ||
*[[Basics]]. | *[[Basics]]. | ||
*[[MEDITECH]]. | *[[MEDITECH]]. | ||
*[[Pathology requisitions]]. | |||
==References== | ==References== | ||