Haukeland University Hospital, 5021 Bergen, Norway.
Hum Pathol. 2011 Jan;42(1):36-40. doi: 10.1016/j.humpath.2010.06.009. Epub 2010 Sep 24.
Complete and accurate histopathology reports are fundamental in providing quality cancer care. The Cancer Registry of Norway and the Norwegian Society of Pathology have previously developed a national electronic template for histopathology reporting on colorectal carcinoma resection specimens. The present study was undertaken to investigate (1) whether quality routines in Norwegian pathology laboratories might affect completeness of such histopathology reports and (2) whether the national electronic template improves completeness of histopathology reports compared with other modes of reporting. A questionnaire on quality routines was sent to the 21 pathology laboratories in Norway. All histopathology reports on colorectal cancer submitted to the Cancer Registry for a 3-month period in the autumn of 2007 were then evaluated on the mode of reporting and the presence of 11 key parameters. Of the 20 laboratories that handled resection specimens, 16 had written guidelines on histopathology reporting. Of these, 4 used the national electronic template, 5 used checklists, 3 used locally developed electronic templates, whereas the remaining 4 had neither obligatory checklists nor templates. Of the 650 histopathology reports submitted to the Cancer Registry in the 3-month period, the national template had been used in 170 cases (26.2%), checklists/locally developed templates in 112 cases (17.2%), and free text in 368 cases (56.6%). Quality routines in the pathology laboratories clearly governed reporting practice and the completeness of the histopathology reports. Use of the national electronic template significantly improved (P < .05) the presence of the 11 key parameters compared with reporting by checklists, locally developed electronic templates, or free text.
完整而准确的组织病理学报告对于提供高质量的癌症护理至关重要。挪威癌症登记处和挪威病理学学会之前已经为结直肠腺癌切除标本的组织病理学报告开发了一个国家电子模板。本研究旨在调查:(1)挪威病理实验室的质量常规是否会影响此类组织病理学报告的完整性;(2)与其他报告模式相比,国家电子模板是否能提高组织病理学报告的完整性。向挪威的 21 个病理实验室发送了一份关于质量常规的问卷。然后,根据报告模式和 11 个关键参数的存在情况,对 2007 年秋季三个月期间向癌症登记处提交的所有结直肠癌组织病理学报告进行了评估。在处理切除标本的 20 个实验室中,有 16 个有组织病理学报告的书面指南。其中,4 个使用国家电子模板,5 个使用检查表,3 个使用本地开发的电子模板,其余 4 个既没有强制性检查表也没有模板。在三个月期间向癌症登记处提交的 650 份组织病理学报告中,有 170 份(26.2%)使用了国家模板,112 份(17.2%)使用了检查表/本地开发的模板,368 份(56.6%)使用了自由文本。病理实验室的质量常规清楚地规范了报告实践和组织病理学报告的完整性。与检查表、本地开发的电子模板或自由文本报告相比,使用国家电子模板显著提高了 11 个关键参数的存在率(P<.05)。