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Do we provide enough information to histopathologist to receive a quality report back? A simple intervention to enhance the clinical details provision to pathology department in a peripheral hospital

Authors:

M. A. C. Lakmal ,

Colombo South Teaching Hospital, LK
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Priyantha Halpage,

Base Hospital, Panadura, LK
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O. N. Perera

Base Hospital, Panadura, LK
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Abstract

Introduction
Adequate clinical details should be provided to histopathologist to obtain a quality report. We experienced shortcomings in histopathology reporting due to deficiencies in patient detail provision.


Method
Retrospective analysis of 100 histopathology specimen forms sent from a surgical unit of Base Hospital Panadura was done. After identifying deficiencies new request form including patient demographic details, contact number, clinical details, relevant blood and biochemical investigation results, clinical diagnosis, space for a line diagram of the specimen with orientating stitches if possible and contact details of the person filled the form, was developed(Image 01). 100 new format forms were prospectively analysed to identify a change.


Results
Conventional forms designed for biochemical studies(Health 350) had been used as histopathology specimen forms as well. Percentages of properly written details were as follows; Patient demographic data -87%, clinical history- 42%, relevant biochemical results-8%,radiological findings-2%,clinical diagnosis -2%. Orientation or a line diagram of the specimen was not mentioned in any forms. After introduction of new format details received were as follows; demographic data -100%, clinical history- 100%, relevant biochemical results-88%, radiological findings-90%, clinical diagnosis -96%. The differences were statistically significant. Line diagram with orientation was included in all relevant specimens.

Conclusion
Considerable deficiency in clinical detail provision with conventional forms was noted in our cohort. The simple intervention of introduction of a spaced, well-formatted request form helped to overcome that deficit. This could be implemented in other hospitals as well.

How to Cite: Lakmal MAC, Halpage P, Perera ON. Do we provide enough information to histopathologist to receive a quality report back? A simple intervention to enhance the clinical details provision to pathology department in a peripheral hospital. Sri Lanka Journal of Surgery. 2020;38(3):35–7. DOI: http://doi.org/10.4038/sljs.v38i3.8770
Published on 31 Dec 2020.
Peer Reviewed

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