Reporting: Difference between revisions
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→Tailoring: Example |
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{{Top | <noinclude>{{Top | ||
|author1=[[User:Mikael Häggström|Mikael Häggström]] | |author1=[[User:Mikael Häggström|Mikael Häggström]] | ||
|author2= | |author2= | ||
}} | }} | ||
Following are general notes on reporting in pathology. | </noinclude>Following are general notes on reporting in pathology. | ||
*'''Save''' your digital work frequently, and also | *'''Save''' your digital work frequently, and also before you leave a computer, even if you think you'll be back shortly. If you have many small specimens to write up in the same report, you may want to save every 2 to 3 specimens. It doesn't matter how much time and effort you spend on something if you're just going to let it disappear in the next glitch. | ||
*'''Double-check''' your report, especially if you copy-pasted and adapted a previous report rather than using a template with blank fields or making your report from scratch. | |||
==Components== | ==Components== | ||
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===Microscopic evaluation=== | ===Microscopic evaluation=== | ||
*'''Specimen chronology''', often A, B, C, etc., at least where there are multiple specimens from the same case. With multiple specimens, preferably write out the chronology for all of them first, so that you don't miss reporting any of them later. | *'''Specimen chronology''', often A, B, C, etc., at least where there are multiple specimens from the same case. With multiple specimens, preferably write out the chronology for all of them first, so that you don't miss reporting any of them later. | ||
*'''Specimen type''' and/or surgery type, such as "appendix, appendectomy", for clarification. This is not necessary at all departments. | *'''Specimen type''' and/or surgery type, such as "appendix, appendectomy", for clarification. This is not necessary at all departments. For the procedure, use the same term as the operating report whenever possible. | ||
*'''Microscopic description'''. This is not always necessary, but should be included if the diagnosis is uncertain. One systematic approach is to describe findings from largest to smallest ones. For example, a description of a tumor can start with the demarcation of the tumor, followed by texture, cell shapes, nucleus shapes and chromatin appearance. | *'''Microscopic description'''. This is not always necessary, but should be included if the diagnosis is uncertain. One systematic approach is to describe findings from largest to smallest ones. For example, a description of a tumor can start with the demarcation of the tumor, followed by texture, cell shapes, nucleus shapes and chromatin appearance. | ||
*'''Diagnosis''' or most probable diagnoses. | *'''Diagnosis''' or most probable diagnoses. | ||
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==Tailoring== | ==Tailoring== | ||
The information contained in the reporting sections in this resource assume that the clinician has requested the exam for the topic at hand, but should still be tailored to any particular questions or requests by the clinician. Any relevant findings beyond the issues or questions raised by the clinician should also be mentioned | The information contained in the reporting sections in this resource assume that the clinician has requested the exam for the topic at hand, but should still be tailored to any particular questions or requests by the clinician. Any relevant findings beyond the issues or questions raised by the clinician should also be mentioned. | ||
The most important findings | As there are generally local practices about how to write reports, it is recommended to have either a personal or practice-specific repository of report templates that you can copy-paste for various cases. When doing so, however, use marks or empty spaces for relevant findings that are frequently changed in the template. Such marks should be conspicuous, so that the report clearly looks unfinished if you haven't tailored it to the case at hand (such as "...measuring _____."). Thereby, you avoid omissions or even wrongly entered information from templates. | ||
The most important findings are preferably moved to '''near the top''' of the report if feasible. | |||
Example of report format: | |||
{|class=wikitable | |||
| A. Organ, side/site, procedure: | |||
*Diagnosis 1. | |||
*Diagnosis 2. | |||
|} | |||
==Wording== | ==Wording== | ||
If a certain '''grammatical rule''' has a risk of making the report less clear to the reader, ignore that rule in that situation. | If a certain '''grammatical rule''' has a risk of making the report less clear to the reader, ignore that rule in that situation. | ||
Restrict '''acronyms/abbreviations''' to those who are certainly well known among all doctors, such as "cm".<ref group= | Restrict '''acronyms/abbreviations''' to those who are certainly well known among all doctors, such as "cm".<ref group=note>Acronyms/abbreviations increase reading speed only if the reader is familiar with the abbreviated terms:</ref> | ||
Generally describe '''what can be seen''' rather than processes (such as preferring "an abundance of" rather than "proliferation of"). | Generally describe '''what can be seen''' rather than processes (such as preferring "an abundance of" rather than "proliferation of"). | ||
If using a dictation device, '''avoid "no"''', and instead use "negative for" (and "positive for" in opposite cases), since there's a risk of "no" not being transcribed and thereby creating the opposite meaning. | If using a dictation device, '''avoid "no"''', and instead use "negative for" (and "positive for" in opposite cases), since there's a risk of "no" not being transcribed and thereby creating the opposite meaning. | ||
Avoid '''"evidence of"''' unless you feel comfortable with the legal implications of its meaning in the report. | |||
Whenever there is text needing '''formatting''' (text size, font type and/or UPPER vs lower case), it is generally most efficient to do it all at once after all the text is written. | |||
==Skin excisions== | ==Skin excisions== | ||