Mathers M E, Shrimankar J, Scott D J, Charlton F G, Griffith C D, Angus B
Department of Histopathology, Royal Victoria Infirmary, Queen Victoria Road, Newcastle upon Tyne NE1 4LP, UK.
J Clin Pathol. 2001 Oct;54(10):809-11. doi: 10.1136/jcp.54.10.809.
To determine whether the introduction of a standard reporting proforma has led to an improvement in the completeness of histopathology reports for breast cancer excision specimens.
A standard reporting proforma was designed using the Royal College of Pathologists' minimum dataset for breast cancer histopathology reports and the national histopathology reporting form of the National Health Service (NHS) breast screening programme. This was introduced into our department in June 1999, with reports generated from the proforma replacing the standard text reports. The pathological information contained in 50 text reports issued before the introduction of the proforma and 50 reports generated using the proforma was compared with the minimum dataset and NHS breast screening programme guidelines.
A general improvement in documentation of individual pathological features was noted after introduction of the proforma. This was most significant in relation to documentation of features, such as microcalcification and ductal carcinoma in situ. In addition, important features such as tumour grade, tumour size, and hormone receptor status were documented more frequently in the proforma group. There was an overall increase in the number of reports regarded as complete after introduction of the proforma.
The introduction of a standard proforma led to a significant improvement in the completeness of breast cancer histopathology reports in this centre, but continued vigilance is needed to ensure that standards continue to improve.
确定引入标准报告模板是否能提高乳腺癌切除标本组织病理学报告的完整性。
使用皇家病理学家学会乳腺癌组织病理学报告的最小数据集和国家医疗服务体系（NHS）乳腺筛查计划的国家组织病理学报告表设计了一个标准报告模板。该模板于1999年6月引入我们科室，模板生成的报告取代了标准文本报告。将模板引入前发布的50份文本报告和使用模板生成的50份报告中包含的病理信息与最小数据集和NHS乳腺筛查计划指南进行比较。
引入模板后，各个病理特征的记录总体上有所改善。这在微钙化和原位导管癌等特征的记录方面最为显著。此外，肿瘤分级、肿瘤大小和激素受体状态等重要特征在模板组中的记录更为频繁。引入模板后，被视为完整的报告数量总体增加。
引入标准模板使该中心乳腺癌组织病理学报告的完整性有了显著提高，但仍需持续保持警惕以确保标准不断提高。
