48,933
edits
Difference between revisions of "Pathology reports"
Jump to navigation
Jump to search
more - add sections
(create) |
(more - add sections) |
||
| Line 3: | Line 3: | ||
==Rules== | ==Rules== | ||
*Diagnostic line should end with a period. | *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== | ==See also== | ||
*[[Basics]]. | *[[Basics]]. | ||
*[[MEDITECH]]. | |||
[[Category:Stuff]] | [[Category:Stuff]] | ||