Path Report Headings

[NuckingFuts]

Hers's a poll for y'all.

I received a phone call from a pathology resident (acquaintance) from a university program, inquiring about headings used in pathology reports.

She narrated a discussion of difference in opinion between two of her attendings.

One attending insisted that the heading in a path report should read what is written on the req form verbatim. For example, the req reads "kidney", therefore the pathology report heading should read "kidney" (followed on the next line by the diagnosis).

The second attending insisted that the heading in the example above should read something like "left kidney, pelvic biopsy" or "right kidney, renal mass, core needle biopsy".

The first attending apparently feels that her method is correct, and in fact explained that the second attending's method violates some sort of CAP guideline, and is a medico-legal no-no, as she is somehow changing the surgeon's designation.

What are your thoughts on this?

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[Neopath]

I've gotten mixed opinions on this, too and it's always an endless source of frustration as I dictate cases for new attendings.

 

[yaah]

I don't think there are any clear guidelines so long as you identify the site. Lots of reports identify the procedure somewhere else in the report as opposed to the diagnostic line.

Our reports just have the specific site followed by diagnosis. The report is otherwise clear that the specimen is a resection, needle biopsy, whatever.

 

[Ruination]

Both places I have trained at used the following:

(Organ or tissue), (situs or more specific anatomic location, e.g. middle lobe), (procedure): Diagnosis.

I think even if the OR nurse is too lazy to scribble down anything more than "kidney" on the bucket, you have an obligation to be as specific as you can in your report. Sometimes this might actually require you to interact with the clinician to get the appropriate information. **** in should not = **** out.

 

[levels x3]

Tissue as labeled on requisition, procedure:
- Diagnosis.

But none of my partners do it exactly the same.

Curious, how does everybody handle products of conception? They are always labeled "products of conception" on the requisition even though that's actually the question. I put it in quotes:

Labeled "products of conception", dilation and curettage:
- Diagnosis.

 

[mlw03]

Tissue as labeled on requisition, procedure:
- Diagnosis.

But none of my partners do it exactly the same.

Curious, how does everybody handle products of conception? They are always labeled "products of conception" on the requisition even though that's actually the question. I put it in quotes:

Labeled "products of conception", dilation and curettage:
- Diagnosis.

In residency we called PoCs, "uterine contents" - so it'd look like:

Uterine contents, dilation and curettage:
- diagnosis

 

[BamaAlum]

In residency we called PoCs, "uterine contents" - so it'd look like:

Uterine contents, dilation and curettage:
- diagnosis

That's how I sign them out (minus the dilation).

 

[pathstudent]

Hers's a poll for y'all.

I received a phone call from a pathology resident (acquaintance) from a university program, inquiring about headings used in pathology reports.

She narrated a discussion of difference in opinion between two of her attendings.

One attending insisted that the heading in a path report should read what is written on the req form verbatim. For example, the req reads "kidney", therefore the pathology report heading should read "kidney" (followed on the next line by the diagnosis).

The second attending insisted that the heading in the example above should read something like "left kidney, pelvic biopsy" or "right kidney, renal mass, core needle biopsy".

The first attending apparently feels that her method is correct, and in fact explained that the second attending's method violates some sort of CAP guideline, and is a medico-legal no-no, as she is somehow changing the surgeon's designation.

What are your thoughts on this?

.

When a neurosurgeon sends something where all it says is "Mass" or "brain tumor", I read his op note and the MRI and then designate it more specifically in my report.

Same with other specimens, like if a GI sends in a specimen that says 60cm. I'll specify that it is colon in my report heading. Also if they give acronyms in the clinical or as the site of nature of the specimen, I'll usually spell it out in the report.

I don't know if this is a CAP phase whatever deficiency or if I'm braking medicolegal laws, but to me it seems like better patient care and I haven't been hassled over it yet.

 

[KCShaw]

Dunno what CAP says about it (however if one is going to make such accusations then that person should point out where they think it says so), but I think it somewhat depends. I don't recall ever changing the surgical/requisition designation on multiple parts (multiple frozens, multiple biopsies) and I think doing so could mislead the surgeon who may have some mystic system for keeping them straight -- and if they don't, well, that's not the pathologist's problem. However when the specimen speaks for itself I'm not sure I have a problem with it, given that how it was "labeled" should be included in the gross description anyway -- i.e., a hastily scrawled "hemi" or "cancer" can become "colon, partial colectomy" or whatever. That said, I do think it's worth being mindful of what you change, what you change it to, and why, as not everything is entirely as it seems.

 

[GeoLeoX]

In the end it's your report with your name on the bottom. Did you do your due diligence to ensure that your report reflects the specimen you received and the diagnosis you rendered? While surgeons cut stuff, internists give medicines, we write reports. That's our product and service. With reporting of certain specimens w/ malignant diagnoses CAP only requires that all scientifically-validated data elements are contained within a single section of the report and that (for the most part) each element is on a line by itself. For medical kidney, "Kidney": would be acceptable. But for a cancer resection with curative intent the side, procedure, etc. should be addressed. If it's a biopsy, then "Kidney": is acceptable, but I think it represents poor attention to patient care - contact the provider, look up the record, etc. This is someone's cancer that you are helping treat.

 

[LADoc00]

First off, ALWAYS suspect anyone who is claiming some strange thing they do is correct because its a "CAP guideline".

That is the surest sign of a tool.

 

[lipomas]

Why do you have to put the procedure in the diagnosis line? Kind of silly. Procedure should be in the history (or "procedure" section if you have one).

 

[deleted314957]

Why do you have to put the procedure in the diagnosis line? Kind of silly. Procedure should be in the history (or "procedure" section if you have one).

i sure as hell don't get much of a history on most of my cases and i don't think i am the exception