Do Surgical Pathology Reports Contain Too Much Information?
N Rassaei, P Cohen, LM Hao, M Pinto, V Parkash. Yale University, New Haven, CT
Background: Surgical pathology reports (SPR) communicate the results of a pathologic evaluation to a clinician. They include fields in addition to the final diagnosis. With an ever increasing array of additional studies and information reported, the SPR has become very long, raising the question as to whether the clinician can expeditiously glean the essential information required for management given the time constraints of practice.
Design: Our SPR contains the following segments: patient demographics, clinical history (as submitted), list of specimen parts, final diagnosis with comments, gross description, frozen section diagnosis, tabulated list of stains, tabulated list of microscopic sections submitted and addenda listing results of additional studies. Previous pathology reports are not included in the final report, but are referenced when pertinent. Clinicians were asked to rank order the parts of the SPR as follows; 1: absolutely essential 2: not as important as 1, but looked at >50% of the time, 3: usually this not reviewed, however, may be important on occasion, 4: Never review, consider removing from standard report, and 5: information not part of the current report but would be useful to have.
Results: 22 clinicians returned our survey. All ranked patient demographics and final diagnosis as the most important segments of the SPR. The summary of sections and list of stains, considered of importance by pathologists, were ranked low (score of 4) by virtually all. Results of additional testing, which at our institution is appended to the tail of the report was felt to be of high importance by oncologists and was rated just below final diagnosis and demographics. The rank order of gross description varied by specimen type and clinician subspecialty. Oncologists in particular considered the inclusion of the previous pathology as important, the others rated this variably.
Conclusions: Pathologists and clinicians rank order differently the various fields of the SPR. Since the purpose of the SPR is to communicate essential and relevant clinical information for management to the clinicians, consideration should be given to recording certain information in the pathology information systems but not reporting generally e.g. summary of sections, list of stains, or details of the IHC procedure (clones, fixation times etc.). These should form part of the intradepartmental chart of the patient to be accessed by clinicians if and when pertinent. Formal surveys of clinicians may help to create SPRs with greater usefulness in clinical practice.
Category: Quality Assurance
Monday, March 22, 2010 1:00 PM
Poster Session II # 210, Monday Afternoon