Difference between revisions of "Pathology reports"

Revision as of 14:50, 5 September 2012

Sign out is the finalization of a case. The term comes from when one used to actually sign the reports.

Formally report addendum.
Used to add material to the report.
Generally, the new material should not substantially contradict the opinion the report.

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.

@@ Line 3: / Line 3: @@
 ==Rules==
 *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 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==
 *[[Basics]].
+*[[MEDITECH]].
 [[Category:Stuff]]