Completeness and adequacy of clinical and demographic information in non- gynaecologic surgical pathology requisition forms: an analysis of 1046 cases

Abstract

Background: An important cornerstone in health care delivery is the field of surgical pathology and one of its major aims is to provide a complete, precise and comprehensive diagnosis within a short period of time. In achieving this, the clinician needs to properly fill a surgical pathology requisition form.

Method: All the consecutive requisition forms from January 1, 2018 to April 30, 2018, totaling 1046 were evaluated for completeness of the information. The requesting clinicians were unaware and cytologic smears were excluded. Patient confidentiality was maintained as no names were recorded. All the Information on the forms was recorded as being present or absent. Analysis was done using the Statistical Package for Social Science version 20.

Results: Altogether 1046 forms were evaluated and (100%) of the sample population bore the surnames and first names. Ages were recorded in 93.7%. Similarly, 68.2% of the forms did not bear the hospital number. Clinical summary and date of request were absent in 42.9% and 35.4% of the forms respectively. Clinicians name/ signature and investigation required were absent in 25.1% and 21.1% of the forms respectively. Overall, 77.6% of information was provided while 22.4% not provided.

Conclusion: The names were completely filled in all the requisition forms. Others were incompletely filled. These findings should be communicated to Clinicians and the recurring attitude of allowing House Officers to fill the requisition forms should be discouraged. Efforts should also be made to let Clinicians appreciate the importance of good clinical information since this determines to a large extent the output of laboratory results.

Keywords: Surgical pathology, requisite form, laboratory result