The impact of template format on the completeness of surgical pathology reports.

CONTEXT

The College of American Pathologists Cancer Case Summaries templates provide a method for including all necessary pathology information in surgical pathology reports with cancer. How effective these templates are at ensuring a complete report, as measured by a separate outside tumor registry, is not known.

OBJECTIVE

To determine factors that correlate with the completeness of the pathology report.

DESIGN

All surgical pathology reports from our hospital (Baptist Hospital of Miami, Miami, Florida) that used templates from January 2004 through February 2013 were reviewed and assessed for completeness by an outside tumor registry.

RESULTS

From 2004 through June 2012, 6139 surgical pathology reports were completed using the template, but only 5151 reports (84%) were complete. For the period January 2012 through June 2012, experienced pathologists who filled out at least 50 templates (n = 3) had a significantly higher completeness rate (187 of 206; 91%) than did pathologists who filled out less than 50 templates (n = 3; 23 of 35; 65%, P < .001) or pathologists who were new to the templates (n = 1; 81 of 104, 78%; P = .002). When the templates were changed by the elimination of all optional information, sequential numbering of all necessary items, and bolding the distance from the closest margin, completeness significantly improved to 98% (313 of 320, P < .001). The improvement remained constant for the 6 months after the changes in format.

CONCLUSIONS

The introduction of simple formatting changes was associated with significantly improved completeness of pathology reports that use the College of American Pathologists Cancer Case Summaries.