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Difference between revisions of "Pathology reports"
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expand -- using Basics article -- move material from there, rename from "Sign out"
m (Haribo moved page Sign out to Pathology reports: more general topic) |
(expand -- using Basics article -- move material from there, rename from "Sign out") |
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'''Sign out''' is the finalization of a case. | '''Pathology reports''' are what [[pathologist]]s produce when finishing a case. '''Sign out''' is the finalization of a case. This article discusses both. | ||
== | The term ''sign out'' 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> | |||
==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> | |||
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. | |||
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> | |||
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> | |||
===Checklists=== | |||
{{Main|CAP checklists}} | |||
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. | |||
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 excellent book about checklists 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=== | |||
Site, operation/procedure:<br> | |||
- Tissue type diagnosis. | |||
Example: | |||
<br> | |||
Gallbladder, cholecystectomy:<br> | |||
- Acute cholecystitis. | |||
==VL formating recommendations== | |||
*Diagnostic line should end with a period. | *Diagnostic line should end with a period. | ||
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*[[Basics]]. | *[[Basics]]. | ||
*[[MEDITECH]]. | *[[MEDITECH]]. | ||
==References== | |||
{{Reflist|2}} | |||
[[Category:Stuff]] | [[Category:Stuff]] | ||