Evaluation of adequacy of histopathology request forms and their role in aiding pathologic diagnosis

Sree Lakshmi K, Raghupathi A R, Biligi D S, Ahmed S M, Natarajan M

Sree Lakshmi K, Raghupathi A R, Biligi D S, Ahmed S M, Natarajan M

Keywords: histopathology, request form, clinical diagnosis, differential diagnosis

Abstract

Background: Information furnished in the histopathology request form is very essential for interpreting the specimen received. Insufficient, incorrect or illegible data on request forms can sometimes result in unintended consequences.
Objective: To assess the quality of information available to the pathologist on the histopathology request forms and its relevance, whether or not a clinical diagnosis was made, were any differential
diagnosis given and the accuracy of the clinical and or differential diagnosis.
Results: Of the 351 requests received only 141 (40.17%) were found adequate. Of these only 11 (3.13%) were 100% adequate and had information for all the 10 parameters present on the request
form. 18/351 (5.12%) of the request forms did not have the requesting clinician’s details. The clinical diagnosis was not specified in 5.4% of the cases. There were 332 cases in which clinical and or differential diagnosis was available. In 269 (81%) cases the histopathology diagnosis matched with the clinical or differential diagnosis.
Conclusion: It was found that most of the request forms were lacking in the information requested. Attempts should be made to educate all the clinicians on the importance of adequately completed request forms.

References

1. Fleming MG. Pigmented lesion pathology: what you should expect from your pathologist, and what your pathologist should expect from you. Clin Plast Surg. 2010;37:1-20.
2. Rademaker M, Thorburn M. Pathology referrals for skin lesions--are we giving the pathologist sufficient clinical information? N Z Med J. 2010;123(1325):53-8
3. Leslie Burnett, Douglas Chesher, Yugan Mudaliar. Improving the quality of information on pathology request forms. Ann Clin Biochem. 2004;41:53-56.
4. Muhammed AS, Sajid M, Nadira M, Shahid J. Clinicin’s responsibility in pre-analytical quality assurance of histopathology. Pak J Med Sci. 2007;23(5):720-3.
5. JL Burton, TJ Stephenson. Are clinicians failing to supply adequate information when requesting a histopathological investigation? J clin Pathol. 2001;54:806- 808.
6. Bankole Henry Oladeine, Richard Omoregie, Eguagie Osareniro Osakue, Adekunle Abdufattai Onifade. Evaluation of laboratory request forms for incomplete data at a rural tertiary hospital in Nigeria. N Z J Med Lab Sci. 2012;66:39-41.
7. Nutt L, Zemlin AE, Erasmus RT. Incomplete laboratory forms: the extent and impact on critical results at a tertiary hospital in South Africa. Ann Clin Biochem. 2008;45(5):463-6.
8. Adegoke OA, Idowu AA and Jeje OA. Incomplete laboratory request forms as a contributory factor to preanalytical errors in a Nigerian teaching hospital. African Journal of Biochemistry Research. 2011;5(3):82-85.
9. Schettini, Daniel Almeida, Schettini, Antonio Pedro Mendes, Sardinha, José Carlos Gomes, Ferreira, Luiz Carlos de Lima, Vasques, Felicien, & Xerez, Luena. Assessment of completion of forms requesting skin biopsies. Anais Brasileiros de Dermatologia. 2012;87(1): 115-118.
10. W G McCluggage. My approach to the interpretation of endometrial biopsies and curettings. J Clin Pathol. 2006; 59(8): 801–812.
11. Leong AS, Braye S, Bhagwandeen B. Diagnostic errors in anatomical pathology: Relevance to Australian laboratories. Pathology. 2006;38(6):490-7.
12. Plebani M. Errors in clinical laboratories or errors in laboratory medicine? Clin Chem Lab Med. 2006;44(6):750-9