Department of Chemical Pathology, SydPath, St Vincent's Hospital, Sydney, NSW, Australia.
University of NSW, Sydney, NSW, Australia.
Clin Chem Lab Med. 2018 Dec 19;57(1):61-65. doi: 10.1515/cclm-2017-1165.
The results of medical laboratory testing are only useful if they lead to appropriate actions by medical practitioners and/or patients. An underappreciated component of the medical testing process is the transfer of the information from the laboratory report into the reader's brain. The format of laboratory reports can be determined by the testing laboratory, which may issue a formatted report, or by electronic systems receiving information from laboratories and controlling the report format. As doctors can receive information from many laboratories, interpreting information from reports in a safe and rapid manner is facilitated by having similar report layouts and formats. Using Australia as an example, there is a wide variation in report formats in spite of a body of work to define standards for reporting. In addition to standardising of report formats, consideration needs to be given to optimisation of report formatting to facilitate rapid and unambiguous reading of the report and also interpretation of the data. Innovative report formats have been developed by some laboratories; however, wide adoption has not followed. The need to balance uniformity of reporting with appropriate innovation is a challenge for safe reporting of laboratory results. This paper discusses the current status and opportunity for improvement in safety and efficiency of the reading of laboratory reports, using current practise and developments in Australia as examples.
如果医学实验室检测结果能够促使医生和/或患者采取相应的措施,那么这些结果才是有用的。然而,人们往往忽略了医学检测流程中的一个重要环节,即将实验室报告中的信息传递到读者的大脑中。实验室报告的格式可以由检测实验室决定,实验室可以采用格式化的报告,也可以通过电子系统从实验室接收信息并控制报告格式。由于医生可能会从多个实验室获取信息,因此如果报告的布局和格式相似,那么医生就能更安全、更快速地解读报告信息。以澳大利亚为例,尽管已经制定了报告标准的相关工作,但报告格式仍存在很大差异。除了报告格式的标准化,还需要考虑优化报告格式,以方便快速、清晰地阅读报告并解读数据。一些实验室已经开发出了创新性的报告格式;然而,这些格式并没有得到广泛采用。在安全报告实验室结果方面,需要平衡报告的一致性和适当的创新性,这是一个挑战。本文以澳大利亚的现行实践和发展为例,讨论了提高实验室报告阅读的安全性和效率的现状和改进机会。