Revealing the missing links in the chain of relevant information from the clinicians to pathologists

Abstract

Objective: To evaluate the adequacy of demographic, clinical, and specimen-related information provided to the histopathology laboratory.

Method: Total 400 biopsy requisition forms were studied retrospectively for the presence and absence of 20 different variables. This cross-sectional and single-centric study was conducted in a tertiary care setting in Peshawar Pakistan in year 2024. Data was collected in Microsoft Excel and analyzed with SPSS v.22. Frequencies, percentages, and mean percentage of the documented variables were determined. Scoring the documented variable as one and the undocumented variable as zero, RFs were scored out of a total score of 20 and mean score was calculated.

Results: Only the name was written on 100% of forms, followed by MRN (95.5%), and the investigation required (91.25%). However, only 36% and 35.75% of forms contained the patient's age and gender respectively. Essential information like clinical history, specimen nature, and site of biopsy were provided on 82.25%, 27.5%, and 50.25% of RFs respectively. Names of the requesting authorities appeared only on 24% forms. No form contained all the 20 variables. The mean percentage of all the documented variables came out to be 39.76%. On scoring, the minimum score was three while the maximum score was 15. The mean and standard deviation of the scores was 7.95±2.74.

Conclusion: Doctors provided the patient identifiers adequately but clinical history and specimen-related data were not adequate. Also, the requesting doctors did not provide their own information on the RFs.

Keywords: Biopsy request; Documentation practices; Information Adequacy; Pathologist; Requisition forms; Scarcity of clinical information.