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Pathology requisitions are the things that come with pathology specimens. They contain a large amount of information and provide context.
- Requisitions are a formal form of communication between healthcare providers and have implications in the quality of care.
- Elements of requisitions, such as the completeness of the clinical history, may be audited as part of a quality program.
Information typically found on requisitions
- Patient identifiers.
- Source of specimen.
- Submitting physican.
- Submitting clinic/operating room.
- Clinical history - considered a necessity and may be a legal requirement.
Standardization of requisitions
Standardization of requsitions:
- Facilitates analysis work, both with respect to: (1) quality of care, and (2) pathophysiology of disease.
- Likely facilitates a higher standard of care, based on the significant body of research on checklist use inside and outside of medicine.
Prostate biopsies - clinical history checklist
- PSA ____ ng/ml.
- Clinical T stage/DRE examination: ___.
- 5-Alpha inhibitor use: Yes/No.
- Previous biopsy: Yes/No.
- Prior radiation therapy: Yes/No.
- Prostate measurements: SAG ___ cm, AP ___ cm, TRANS ___ cm.
- Prostate volume: ___ cm3.
- PSA density ___ ng/ml2.
- Additional clinical information: ___.
Urinary bladder biopsies/TURBTs - clinical history checklist
- History of bladder tumour: No/Yes.
- BCG treatment: Yes/No.
- Erythema: Yes/No.
- Definite tumour: Yes/No.
- Location of tumour: ___.
- Clinical stage: ___.
- Other clinical information: ___.
Lung mass - clinical history checklist
- Previous lung biopsy: No/Yes.
- History of cancer: No/Yes - primary site _______.
- Suspected cancer: No/Yes
- If Yes: primary lung/metastasis, clinical stage _______.
- Exposure history, e.g. smoking: _______.
- Other relevant information: _______.
- Colonoscopy reporting form - BC Cancer Agency (bccancer.bc.ca).
- Colonoscopy reporting form - Intructions - BC Cancer Agency (bccancer.bc.ca).
- Benard, M.; Bouaud, J.; Marsault, C.; Boudghene, F.; Carette, MF.; Séroussi, B. (2015). "Diagnostic imaging requisition quality when using an electronic medical record: a before-after study.". Stud Health Technol Inform 210: 364-8. PMID 25991167.
- Duggan MA and Trotter T. "Alberta Health Services: Anatomical Pathology Quality Assurance Plan". Canadian Journal of Pathology. 2016;8(3):10-35.
- Nakhleh, RE.; Gephardt, G.; Zarbo, RJ. (Jul 1999). "Necessity of clinical information in surgical pathology.". Arch Pathol Lab Med 123 (7): 615-9. doi:10.1043/0003-9985(1999)123<0615:NOCIIS>2.0.CO;2. PMID 10388918.
- R.R.O. 1990, Reg. 965, s. 31 (1). URL: http://www.ontario.ca/laws/regulation/900965#BK23. Accessed on: 18 December 2015.
- Soar J, Peyton J, Leonard M, Pullyblank AM (2009). "Surgical safety checklists". BMJ 338: b220. PMID 19158173. http://bmj.com/cgi/pmidlookup?view=long&pmid=19158173.
- Gawande A. The checklist manifesto: How to get things right. Metropolitan Books. 2009. URL: http://www.amazon.com/dp/0805091742. ISBN-13 978-0805091748.