Clinician Compliance with Laboratory Regulations Requiring Submission of Appropriate Clinical Data: A One Year Retrospective Analysis
Lester J Layfield, Rachel E Factor, Elke A Jarboe. University of Utah, Salt Lake City, UT; ARUU Laboratories, Salt Lake City, UT
Background: The evaluation of tissue samples submitted to Surgical Pathology is a consultation composed of evaluation of pertinent patient history, clinical findings and morphologic analysis. The College of American Pathologists (CAP) recognizes the need for clinical data in the interpretation of specimens submitted for histopathologic evaluation. The CAP regulation (CAP GEN.40100 Specimen Collection Manual Elements) includes instructions for a number of elements which include the need for appropriate clinical data, when indicated. In a note they state, “Because of the importance of clinical information in the practice of Surgical Pathology and Cytopathology, requisitions for such specimens should include pertinent clinical data, as well as preoperative and postoperative diagnosis.” Anecdotal evidence indicates that clinician compliance with such requests is variable and at times poor.
Design: ARUP Laboratories and the Department of Pathology at the University of Utah have recognized inclusion of clinical history on Surgical Pathology request forms as a clinical indicator for quality assurance. The quality assurance data from August 1, 2010 to September 31, 2011 were searched for all cases flagged as containing no clinical history. Additionally, four consecutive weeks of Surgical Pathology request forms were reviewed to determine the presence or absence of clinical history, correlation was made with specimen type and clinical service requesting the pathology consultation. QA data was also reviewed to determine if the clinical history was accurate.
Results: Between August 1, 2010 and July 31, 2011, 21,700 surgical pathology cases were accessioned. Within this group, 1,293 (5.9%) requisitions contained no clinical history. The four week review found that 140 of 1,698 (8.2%) of requisitions contained no clinical history or only a specimen site of origin. This analysis also revealed that 4 cases contained substantially incorrect or incomplete clinical history (0.2%).
Conclusions: Our review indicates a significant number (5.9%) of requisitions contain no clinical history on the request form. A more in depth review reveals that approximately 8% contain either no clinical history or simply a body site in the clinical history request area and in 0.2% of cases, the clinical history was factually incorrect. Compliance with requirements for clinical history is poor and reveals the need to educate clinicians to provide this information.
Category: Quality Assurance
Monday, March 19, 2012 1:00 PM
Poster Session II # 272, Monday Afternoon