Pathology reports

From Libre Pathology
Revision as of 11:03, 6 September 2012 by Michael (talk | contribs) (Haribo moved page Sign out to Pathology reports: more general topic)
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Sign out is the finalization of a case. The term comes from when one used to actually sign the reports.

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