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Difference between revisions of "Pathology reports"
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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]. | ||
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 | 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> | ||
===Standard diagnostic notation=== | ===Standard diagnostic notation=== | ||
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- Acute cholecystitis. | - Acute cholecystitis. | ||
==''Libre Pathology'' | ==Formatting recommendations used on ''Libre Pathology''== | ||
===Diagnosis=== | ===Diagnosis=== | ||
*The tissue type/site usually should be what the clinician submitted it as. | *The tissue type/site usually should be what the clinician submitted it as. | ||
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*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> | *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> | ||
**''Negative'' and ''without'' are preferred. | **''Negative'' and ''without'' are preferred. | ||
====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==== | ||
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*[[Basics]]. | *[[Basics]]. | ||
*[[MEDITECH]]. | *[[MEDITECH]]. | ||
*[[Pathology requisitions]]. | |||
==References== | ==References== | ||