Difference between revisions of "Pathology reports"

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Pathology reports (view source)

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The term ''sign out'' is from when one used to actually sign the reports.
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%!<ref name=pmid10888781>{{Cite journal  | last1 = Powsner | first1 = SM. | last2 = Costa | first2 = J. | last3 = Homer | first3 = RJ. | title = Clinicians are from Mars and pathologists are from Venus. | journal = Arch Pathol Lab Med | volume = 124 | issue = 7 | pages = 1040-6 | month = Jul | year = 2000 | doi = 10.1043/0003-9985(2000)1241040:CAFMAP2.0.CO;2 | PMID = 10888781 }}</ref>
The key point in report writing is that the report should be precise, complete and easy-to-understand.  Many pathology reports, unfortunately, are misunderstood by surgeons; one study suggests that it is 30%!<ref name=pmid10888781>{{Cite journal  | last1 = Powsner | first1 = SM. | last2 = Costa | first2 = J. | last3 = Homer | first3 = RJ. | title = Clinicians are from Mars and pathologists are from Venus. | journal = Arch Pathol Lab Med | volume = 124 | issue = 7 | pages = 1040-6 | month = Jul | year = 2000 | doi = 10.1043/0003-9985(2000)1241040:CAFMAP2.0.CO;2 | PMID = 10888781 }}</ref>


==Standards==
==Standards==
Based on a PubMed search,<ref>URL: [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=PureSearch&db=PubMed&details_term=standardization,%20surgical%20pathology%20report Pubmed search for ''standardization, surgical pathology report'']. </ref> the first papers on the topic of standards were written in 1992!<ref name=pmid1574498>{{cite journal |author=Rosai J, Bonfiglio TA, Corson JM, ''et al.'' |title=Standardization of the surgical pathology report |journal=Mod. Pathol. |volume=5 |issue=2 |pages=197–9 |year=1992 |month=March |pmid=1574498 |doi= |url=}}</ref><ref name=pmid1574486>{{cite journal |author=Frable WJ, Kempson RL, Rosai J |title=Quality assurance and quality control in anatomic pathology: standardization of the surgical pathology report |journal=Mod. Pathol. |volume=5 |issue=2 |pages=102a–102b |year=1992 |month=March |pmid=1574486 |doi= |url=}}</ref>
Based on a PubMed search,<ref>URL: [http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=PureSearch&db=PubMed&details_term=standardization,%20surgical%20pathology%20report Pubmed search for ''standardization, surgical pathology report'']. </ref> the first papers on the topic of standards were written in 1992!<ref name=pmid1574498>{{cite journal |author=Rosai J, Bonfiglio TA, Corson JM, ''et al.'' |title=Standardization of the surgical pathology report |journal=Mod. Pathol. |volume=5 |issue=2 |pages=197–9 |year=1992 |month=March |pmid=1574498 |doi= |url=}}</ref><ref name=pmid1574486>{{cite journal |author=Frable WJ, Kempson RL, Rosai J |title=Quality assurance and quality control in anatomic pathology: standardization of the surgical pathology report |journal=Mod. Pathol. |volume=5 |issue=2 |pages=102a–102b |year=1992 |month=March |pmid=1574486 |doi= |url=}}</ref>


There is no universal standard; however, there is a push to standardize by the ''Association of Directors of Anatomic and Surgical Pathology'',<ref>URL: [http://www.adasp.org/papers/position/Standardization.htm http://www.adasp.org/papers/position/Standardization.htm]</ref> among others.
There is no universal standard; however, there is a push to standardize by the ''Association of Directors of Anatomic and Surgical Pathology'',<ref>URL: [http://www.adasp.org/papers/position/Standardization.htm http://www.adasp.org/papers/position/Standardization.htm]. Accessed on: 6 September 2012.</ref> among others.


Standards lead to uniformity and consistency.<ref name=pmid7878300>{{cite journal |author=Leslie KO, Rosai J |title=Standardization of the surgical pathology report: formats, templates, and synoptic reports |journal=Semin Diagn Pathol |volume=11 |issue=4 |pages=253–7 |year=1994 |month=November |pmid=7878300 |doi= |url=}}</ref>
Standards appear to lead to uniformity and consistency.<ref name=pmid7878300>{{cite journal |author=Leslie KO, Rosai J |title=Standardization of the surgical pathology report: formats, templates, and synoptic reports |journal=Semin Diagn Pathol |volume=11 |issue=4 |pages=253–7 |year=1994 |month=November |pmid=7878300 |doi= |url=}}</ref>


Something close to a standard is laid-out in by Goldsmith et al.<ref name=pmid18834219>{{Cite journal  | last1 = Goldsmith | first1 = JD. | last2 = Siegal | first2 = GP. | last3 = Suster | first3 = S. | last4 = Wheeler | first4 = TM. | last5 = Brown | first5 = RW. | title = Reporting guidelines for clinical laboratory reports in surgical pathology. | journal = Arch Pathol Lab Med | volume = 132 | issue = 10 | pages = 1608-16 | month = Oct | year = 2008 | doi = 10.1043/1543-2165(2008)132[1608:RGFCLR]2.0.CO;2 | PMID = 18834219 }}</ref>
Something close to a standard is laid-out in by Goldsmith et al.<ref name=pmid18834219>{{Cite journal  | last1 = Goldsmith | first1 = JD. | last2 = Siegal | first2 = GP. | last3 = Suster | first3 = S. | last4 = Wheeler | first4 = TM. | last5 = Brown | first5 = RW. | title = Reporting guidelines for clinical laboratory reports in surgical pathology. | journal = Arch Pathol Lab Med | volume = 132 | issue = 10 | pages = 1608-16 | month = Oct | year = 2008 | doi = 10.1043/1543-2165(2008)132[1608:RGFCLR]2.0.CO;2 | PMID = 18834219 }}</ref>
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The College of American Pathologists (CAP) has checklists for cancer - [http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=committees%2Fcancer%2Fcancer_protocols%2Fprotocols_index.html&_state=maximized&_pageLabel=cntvwr CAP protocols].
The College of American Pathologists (CAP) has checklists for cancer - [http://www.cap.org/apps/cap.portal?_nfpb=true&cntvwrPtlt_actionOverride=%2Fportlets%2FcontentViewer%2Fshow&_windowLabel=cntvwrPtlt&cntvwrPtlt%7BactionForm.contentReference%7D=committees%2Fcancer%2Fcancer_protocols%2Fprotocols_index.html&_state=maximized&_pageLabel=cntvwr 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.   
It seems likely that pathologists will use more checklists in the future... they are deemed effective in a number of places inside and outside of medicine.  Good evidence suggests that surgical checklists reduces adverse events.<ref name=pmid19158173>{{cite journal |author=Soar J, Peyton J, Leonard M, Pullyblank AM |title=Surgical safety checklists |journal=BMJ |volume=338 |issue= |pages=b220 |year=2009 |pmid=19158173 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=19158173}}</ref> Pilots have been using checklists since the 1930s.<ref name=gawande>Gawande A. The checklist manifesto: How to get things right. Metropolitan Books. 2009. URL: [http://www.amazon.com/dp/0805091742 http://www.amazon.com/dp/0805091742]. ISBN-13 978-0805091748.</ref>
Surgeons know that checklists work and that they save lives.<ref name=pmid19158173>{{cite journal |author=Soar J, Peyton J, Leonard M, Pullyblank AM |title=Surgical safety checklists |journal=BMJ |volume=338 |issue= |pages=b220 |year=2009 |pmid=19158173 |doi= |url=http://bmj.com/cgi/pmidlookup?view=long&pmid=19158173}}</ref>
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.<ref>Gawande A. The checklist manifesto: How to get things right. Metropolitan Books. 2009. URL: [http://www.amazon.com/dp/0805091742 http://www.amazon.com/dp/0805091742]. ISBN-13 978-0805091748.</ref>


===Standard diagnostic notation===
===Standard diagnostic notation===
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- Acute cholecystitis.
- Acute cholecystitis.


==''Onlinepathology'' formating recommendations==
==Formatting recommendations used on ''Libre Pathology''==
===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.
*Each diagnostic line should end with a period or semicolon.
**Punctuation experts are somewhat divided on what to do here.<ref>URL: [http://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html phttp://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html]. Accessed on: 10 January 2014.</ref><ref>URL: [http://www.ossweb.com/article-bullets.html http://www.ossweb.com/article-bullets.html]. Accessed on: 10 January 2014.</ref>
**Punctuation experts are somewhat divided on what to do here.<ref>URL: [http://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html phttp://www.businesswritingblog.com/business_writing/2012/01/punctuating-bullet-points-.html]. Accessed on: 10 January 2014.</ref><ref>URL: [http://www.ossweb.com/article-bullets.html http://www.ossweb.com/article-bullets.html]. Accessed on: 10 January 2014.</ref>
**The advantage of using a period or semicolon is: the end the diagnostic line is clearly marked.
**The advantage of using a period or semicolon is: the end the diagnostic line is clearly marked.
*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''.
*It is best to avoid ''no'' and ''not'', as these may be lost at transcription or overlooked.<ref>{{Cite journal  | last1 = Renshaw | first1 = MA. | last2 = Gould | first2 = EW. | last3 = Renshaw | first3 = A. | title = Just say no to the use of no: alternative terminology for improving anatomic pathology reports. | journal = Arch Pathol Lab Med | volume = 134 | issue = 9 | pages = 1250-2 | month = Sep | year = 2010 | doi = 10.1043/2010-0031-SA.1 | PMID = 20807042 }}</ref>
*If several diagnoses are made, the most clinically important diagnosis should be listed first.
**''Negative'' and ''without'' are preferred.
*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.
====Uncertainty====
*Uncertainty in reports can be conveyed with various terms.  
*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.
**''Suggestive of ...'' (57) conveys a lesser level of uncertainty.
**''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''.
**Patients often read their reports. Abbreviations muddle things.
**Patients often read their reports. Abbreviations muddle things.


===Microscopic===
===Microscopic===
*One should assume it isn't going to be read.
:[[AKA]] ''microscopy''.
*Describes how the tissue looks under the microscope.<ref>URL: [http://www.cancer.gov/cancertopics/factsheet/detection/pathology-reports http://www.cancer.gov/cancertopics/factsheet/detection/pathology-reports]. Accessed on: 24 April 2014.</ref>
 
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.
*Immunostains should be reported as a comment in the ''diagnosis'' section.
**Many labs report IHC in the ''microscopic'' section.<ref name=pmid18834219>{{Cite journal  | last1 = Goldsmith | first1 = JD. | last2 = Siegal | first2 = GP. | last3 = Suster | first3 = S. | last4 = Wheeler | first4 = TM. | last5 = Brown | first5 = RW. | title = Reporting guidelines for clinical laboratory reports in surgical pathology. | journal = Arch Pathol Lab Med | volume = 132 | issue = 10 | pages = 1608-16 | month = Oct | year = 2008 | doi = 10.1043/1543-2165(2008)132[1608:RGFCLR]2.0.CO;2 | PMID = 18834219 }}</ref>
*Internal reviews/consults should likewise not be found here; they should be in 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.


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*[[Basics]].
*[[Basics]].
*[[MEDITECH]].
*[[MEDITECH]].
*[[Pathology requisitions]].


==References==
==References==
Michael
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