Pathology reports - Revision history

Michael: /* Dealing with errors and when to use an amendment */

2025-04-29T19:42:08Z

Dealing with errors and when to use an amendment

← Older revision		Revision as of 19:42, 29 April 2025
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	* Clearly state what the diagnosis was previously.		* Clearly state what the diagnosis was previously.
	* Have another pathologist confirm the revised diagnosis.		* Have another pathologist confirm the revised diagnosis.
			* Communicate directly with the most responsible physician - make them aware of the change.
			* Document the communication.

	==See also==		==See also==

Michael at 19:39, 29 April 2025

2025-04-29T19:39:18Z

← Older revision		Revision as of 19:39, 29 April 2025
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	===Amendment===		===Amendment===
	*Formally ''report amendment''.		*Formally ''report amendment''.
	*Used to change the [[diagnosis]] or significant interpretations in the report.		*Used to change the [[diagnosis]] ''or'' significant interpretations in the report.

	==Dealing with errors==		==Dealing with errors and when to use an amendment==
	{{Main\|Quality}}		{{Main\|Quality}}

	~~===Addendum versus amendment for errors===~~		*If an addendum would add information to the report that contradicts other information already in the report: it should be an amendment (not an addendum).<ref name=pmid25357114>{{cite journal \|authors=Babwah JP, Khalifa M, Rowsell C \|title=Analysis of addenda in anatomic pathology as a quality monitoring initiative \|journal=Arch Pathol Lab Med \|volume=138 \|issue=11 \|pages=1514–9 \|date=November 2014 \|pmid=25357114 \|doi=10.5858/arpa.2012-0412-OA \|url=}}</ref>
	~~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.

	~~====Bottom line====~~
	If an addendum ~~adds~~ information to the report that contradicts other information: it should be an amendment (not an addendum).<ref name=pmid25357114>{{cite journal \|authors=Babwah JP, Khalifa M, Rowsell C \|title=Analysis of addenda in anatomic pathology as a quality monitoring initiative \|journal=Arch Pathol Lab Med \|volume=138 \|issue=11 \|pages=1514–9 \|date=November 2014 \|pmid=25357114 \|doi=10.5858/arpa.2012-0412-OA \|url=}}</ref>

	It is good practice when amending an report to:		It is good practice when amending an report to:

Michael: /* Bottom line */

2025-04-29T14:15:48Z

Bottom line

← Older revision		Revision as of 14:15, 29 April 2025
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	====Bottom line====		====Bottom line====
	If an addendum adds information that ~~is contradictory~~: it should be an amendment.<ref>{{cite journal \|authors=Babwah JP, Khalifa M, Rowsell C \|title=Analysis of addenda in anatomic pathology as a quality monitoring initiative \|journal=Arch Pathol Lab Med \|volume=138 \|issue=11 \|pages=1514–9 \|date=November 2014 \|pmid=25357114 \|doi=10.5858/arpa.2012-0412-OA \|url=}}</ref>		If an addendum adds information to the report that contradicts other information: it should be an amendment (not an addendum).<ref name=pmid25357114>{{cite journal \|authors=Babwah JP, Khalifa M, Rowsell C \|title=Analysis of addenda in anatomic pathology as a quality monitoring initiative \|journal=Arch Pathol Lab Med \|volume=138 \|issue=11 \|pages=1514–9 \|date=November 2014 \|pmid=25357114 \|doi=10.5858/arpa.2012-0412-OA \|url=}}</ref>

	It is good practice when amending an report to:		It is good practice when amending an report to:

Michael: /* Dealing with errors */

2025-04-29T14:13:53Z

Dealing with errors

← Older revision		Revision as of 14:13, 29 April 2025
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	====Bottom line====		====Bottom line====
	If an addendum adds information that is contradictory: it should be an amendment.<ref>{{cite journal \|authors=Babwah JP, Khalifa M, Rowsell C \|title=Analysis of addenda in anatomic pathology as a quality monitoring initiative \|journal=Arch Pathol Lab Med \|volume=138 \|issue=11 \|pages=1514–9 \|date=November 2014 \|pmid=25357114 \|doi=10.5858/arpa.2012-0412-OA \|url=}}</ref>		If an addendum adds information that is contradictory: it should be an amendment.<ref>{{cite journal \|authors=Babwah JP, Khalifa M, Rowsell C \|title=Analysis of addenda in anatomic pathology as a quality monitoring initiative \|journal=Arch Pathol Lab Med \|volume=138 \|issue=11 \|pages=1514–9 \|date=November 2014 \|pmid=25357114 \|doi=10.5858/arpa.2012-0412-OA \|url=}}</ref>

			It is good practice when amending an report to:
			* Clearly state the revised diagnosis.
			* Clearly note that the diagnosis was changed.
			* Clearly state what the diagnosis was previously.
			* Have another pathologist confirm the revised diagnosis.

	==See also==		==See also==

Michael: /* Dealing with errors */

2025-04-29T14:10:45Z

Dealing with errors

← Older revision		Revision as of 14:10, 29 April 2025
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	==Dealing with errors==		==Dealing with errors==
	{{Main\|Quality}}		{{Main\|Quality}}
	*Opinion is split on whether reports should be ''amended'' or ''addended''.

	===Addendum versus amendment for errors===		===Addendum versus amendment for errors===
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	*CONS:		*CONS:
	**Change in report may not be apparent -- depends on information management system.		**Change in report may not be apparent -- depends on information management system.

			====Bottom line====
			If an addendum adds information that is contradictory: it should be an amendment.<ref>{{cite journal \|authors=Babwah JP, Khalifa M, Rowsell C \|title=Analysis of addenda in anatomic pathology as a quality monitoring initiative \|journal=Arch Pathol Lab Med \|volume=138 \|issue=11 \|pages=1514–9 \|date=November 2014 \|pmid=25357114 \|doi=10.5858/arpa.2012-0412-OA \|url=}}</ref>

	==See also==		==See also==

Michael: /* See also */

2017-04-12T15:44:34Z

Michael: /* Uncertainty */

2017-03-16T04:20:28Z

Uncertainty

← Older revision		Revision as of 04:20, 16 March 2017
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	====Uncertainty====		====Uncertainty====
	*Uncertainty in reports can be conveyed with various terms.		*Uncertainty in reports can be conveyed with various terms.
	*There is no standard but the interpretation (by clinicians and pathologists) of various ~~phrase~~ have been compared by Lindley ''et al.'' using a scale of 0 (uncertain) to 100 (certain):<ref name=pmid24939143>{{Cite journal \| last1 = Lindley \| first1 = SW. \| last2 = Gillies \| first2 = EM. \| last3 = Hassell \| first3 = LA. \| title = Communicating diagnostic uncertainty in surgical pathology reports: disparities between sender and receiver. \| journal = Pathol Res Pract \| volume = 210 \| issue = 10 \| pages = 628-33 \| month = Oct \| year = 2014 \| doi = 10.1016/j.prp.2014.04.006 \| PMID = 24939143 }}</ref>		*There is no standard but the interpretation (by clinicians and pathologists) of various phrases have been compared by Lindley ''et al.'' using a scale of 0 (uncertain) to 100 (certain):<ref name=pmid24939143>{{Cite journal \| last1 = Lindley \| first1 = SW. \| last2 = Gillies \| first2 = EM. \| last3 = Hassell \| first3 = LA. \| title = Communicating diagnostic uncertainty in surgical pathology reports: disparities between sender and receiver. \| journal = Pathol Res Pract \| volume = 210 \| issue = 10 \| pages = 628-33 \| month = Oct \| year = 2014 \| doi = 10.1016/j.prp.2014.04.006 \| PMID = 24939143 }}</ref>
	**''Cannot rule out'' (55) and ''indefinite for ...'' (52) convey the highest level of uncertainty among attending clinicians.		**''Cannot rule out'' (55) and ''indefinite for ...'' (52) convey the highest level of uncertainty among attending clinicians.
	**''Suggestive of ...'' (57) conveys a lesser level of uncertainty.		**''Suggestive of ...'' (57) conveys a lesser level of uncertainty.
	**''Consistent with ...'' (76) seems to be ignored by many.		**''Consistent with ...'' (76) seems to be ignored by many.

	====Abbreviations====		====Abbreviations====
	*[[Abbreviations]] should not be used, e.g. [[LEEP]] should be written-out as ''loop electrosurgical excision procedure''.		*[[Abbreviations]] should not be used, e.g. [[LEEP]] should be written-out as ''loop electrosurgical excision procedure''.

Michael: /* Formatting recommendations used on Libre Pathology */

2017-03-16T04:19:28Z

Formatting recommendations used on Libre Pathology

← Older revision		Revision as of 04:19, 16 March 2017
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	**''Negative'' and ''without'' are preferred.		**''Negative'' and ''without'' are preferred.

			====Uncertainty====
			*Uncertainty in reports can be conveyed with various terms.
			*There is no standard but the interpretation (by clinicians and pathologists) of various phrase have been compared by Lindley ''et al.'' using a scale of 0 (uncertain) to 100 (certain):<ref name=pmid24939143>{{Cite journal \| last1 = Lindley \| first1 = SW. \| last2 = Gillies \| first2 = EM. \| last3 = Hassell \| first3 = LA. \| title = Communicating diagnostic uncertainty in surgical pathology reports: disparities between sender and receiver. \| journal = Pathol Res Pract \| volume = 210 \| issue = 10 \| pages = 628-33 \| month = Oct \| year = 2014 \| doi = 10.1016/j.prp.2014.04.006 \| PMID = 24939143 }}</ref>
			**''Cannot rule out'' (55) and ''indefinite for ...'' (52) convey the highest level of uncertainty among attending clinicians.
			**''Suggestive of ...'' (57) conveys a lesser level of uncertainty.
			**''Consistent with ...'' (76) seems to be ignored by many.

	====Abbreviations====		====Abbreviations====
	*[[Abbreviations]] should not be used, e.g. [[LEEP]] should be written-out as ''loop electrosurgical excision procedure''.		*[[Abbreviations]] should not be used, e.g. [[LEEP]] should be written-out as ''loop electrosurgical excision procedure''.

Michael: /* Libre Pathology formating recommendations */

2017-03-16T04:00:42Z

Libre Pathology formating recommendations

← Older revision		Revision as of 04:00, 16 March 2017
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	- Acute cholecystitis.		- Acute cholecystitis.

	==''Libre Pathology'' ~~formating recommendations~~==		==Formatting recommendations used on ''Libre Pathology''==
	===Diagnosis===		===Diagnosis===
	*The tissue type/site usually should be what the clinician submitted it as.		*The tissue type/site usually should be what the clinician submitted it as.

Michael: /* Checklists */ fix

2015-08-31T12:46:30Z

Checklists: fix

← Older revision		Revision as of 12:46, 31 August 2015
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	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].		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].

	It seems likely that pathologists will use more checklists in the future... they are deemed effective in a number of places inside and outside of medicine. Good evidence suggests that surgical checklists reduces adverse events.<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.<ref name=gawande/>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>		It seems likely that pathologists will use more checklists in the future... they are deemed effective in a number of places inside and outside of medicine. Good evidence suggests that surgical checklists reduces adverse events.<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.<ref name=gawande>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===		===Standard diagnostic notation===

← Older revision		Revision as of 15:44, 12 April 2017
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	*[[Basics]].		*[[Basics]].
	*[[MEDITECH]].		*[[MEDITECH]].
			*[[Pathology requisitions]].

	==References==		==References==